MEMORANDUM ON THE IMPLEMENTATION OF THE CHOICE OF TERMINATION OF PREGNANCY ACT, ACT 92 OF 1996

TO: PORTFOLIO COMMITTEE ON HEALTH

PREPARED BY: DEMOCRATIC NURSING ORGANISATION OF SOUTH

AFRICA (DENOSA)

DATE: 7 JUNE 2000

INTRODUCTION

Recently so much has been reported in the printed media, the television and radio on the implementation of the Choice of Termination on Pregnancy (CTOP) Act (Act No 92 of 1996). Basically all is not well and the fingers are being pointed mostly at the nurses and doctors. As said by the National Director of Maternal, Child and Women’s Health at the Department of Health, in one of the papers, this is a gradual process and it involves changing people’s attitudes. To us as DENOSA, the people referred to here are not only nurses and doctors but changing of attitudes of the society at large. Given the South African society’s cultural diversities, major strides have been made.

However during 1996/97 DENOSA did a survey to determine a profile of the nursing profession. One of the questions asked was on the support for the termination of pregnancy and the outcome indicated that 64% of the profession did not support TOP.

DENOSA’s submission is based on reports submitted by its members, interviews with nurses and midwives employed in institutions offering termination of pregnancy services and relevant literature. The introduction of CTOP Act has made freedom of choice based on the determination in section 12(2)(a) of the Constitution of South Africa a reality. The Act has created a legal framework in which all women have been afforded the right to make choices about their bodies and their reproductive health.

IMPLEMENTATION OF THE ACT

While the CTOP Act has legalised abortion services and made such services more readily available, many problems are still being experienced with the implementation of the services.

The issues will be discussed under three headings and based on the fact that DENOSA is a professional organisation and a trade union for nurses and midwives, the issues pertaining to the nurse/midwife will be discussed first.

  1. The Nurse and Midwife
    1. Caring of the Carers

TOP is and will always remain an emotional issue and no client finds it an easy decision to make. The atmosphere in the workplace is an emotional one which affect all the staff working in that unit. Lack of counselling services for nurses, midwives and other health care workers involved in TOP service delivery is a matter of great concern. Staff appears to be demoralised and suffer from burnout.

Proposal:

  1. Counselling services for all personnel working in a unit where termination of pregnancies are performed should be regarded as a priority and implemented as soon as possible. (The study done by Gmeiner et al in 2000 gives an indication of how this can be done).
  2. Support groups for personnel should be established to ensure that they have an opportunity to work through emotions on a regular basis.
  3. Adequate staff: patient ratios should be developed and implemented to ensure that there are sufficient staff available to prevent burnout.
    1. TOP Training for midwives

1.2.1 Number of midwives trained

Only a small number of midwives have undergone the post basic programme which enables them to do TOP. Research has proven that the midwives are skilled in the clinical diagnosis of gestational age and the performance of manual vacuum aspiration (MVA) in uncomplicated, incomplete abortions. To date 92 midwives have completed the theoretical training. Of this group 81 have completed clinical training. The rate of training is totally inadequate to meet the needs of the health services and the need for equal access.

1.2.2 Choosing to train for TOP

Midwives involved in TOP services opt to do so and therefore must make an active choice to do the post basic training programme for TOP. This creates a difficult situation for many of them. Midwives from Mpumalanga and Northern Province have verbalised that they are being labeled, victimised and discriminated against by their other colleagues and in some instances the community, for choosing to be involved in the performance of termination of pregnancy.

1.2.3 Lack of diversity

Midwives trained to provide TOP services, find that they usually end up doing only TOP’s with no opportunity to perform other duties that midwives are involved in.

1.2.4 Utilisation of trained midwives

Another problem currently being experienced is that midwives with specialised skills in TOP and advanced midwifery are frequently promoted or transferred to other, non-midwifery units such as management or head office, where their specialised skills are not being utilised where it is needed most.

1.2.5 Private sector

Midwives from the private sector who have declared themselves willing and available have found it impossible to access the required TOP training programmes. The private sector can play an important role in extending the services available to the public as well as extending the training opportunities.

Proposal:

  1. Training for midwives should be accelerated and should include midwives from the private sector.
  2. The Act should be amended to enable other nurses, such as those doing family planning, to also offer TOP services.
  3. Consideration should be given to creative distance learning programmes with limited contact hours and supervisors to monitor clinical skills development. Partnerships should be established with NGO’s involved in these programmes.
  4. Advanced midwives and midwives trained in TOP should be retained in the relevant service areas where their specialised skills are required and not be transferred to other units where their specialised skills are not fully utilised.
  5. Although regarded as controversial, consideration should be given to the inclusion of skills for the termination of pregnancy in the basic training of midwives.
  6. The Employer must protect the midwives involved in TOP services.

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    1. Other personnel

1.3.1 Management

The attitude of the management of an institution can complicate the service delivery by, for example, placing the service in an area far away from all other services such as sonar and emergency care services. A concerted effort must be made to convince management of the need to support and become involved in the implementation of services.

1.3.2 Conscience clause

The CTOP Act does not have a conscience clause that protects the person who objects to abortion on grounds of conscience from participation in the termination of pregnancy. This is experienced as a problem by some personnel and has served to further anger the anti-choice movement.

Proposal:

  1. Value clarification workshops for all the staff in institutions where TOP is available can contribute to a more open and unjudgemental attitude amongst the staff, for each other and the client. This includes the security staff who often is the first contact of the client with the service facility.
  2. Value clarification workshops should take place regularly and on an ongoing basis in order to build the understanding of all involved and elicit support.

    1. Legal implications and the techniques used for TOP

It is unclear whether the Medicines Control Council has approved Misoprostol as a drug for the induction of abortion. If the nurse/midwife administers this medication to the patient, even on the prescription of the medical practitioner, she/he becomes co-responsible for the outcome of the administration. Should the client develop any complications as a result of the medication, or if she does not abort and the baby is born with malformation as a result of the Misoprostol, the consequences for both the health care worker and the institution can be extremely serious, especially if the medication has not been approved for such use. The question also arises whether indemnity insurance schemes will cover such an incident.

Proposal:

  1. The position of the MCC on the use of Misoprostol be obtained and made known to the stakeholders.
  2. Legal clarity be obtained from the State Attorney on the use of a drug for an unregistered purpose and the legal status and accountability of the prescriber and administrator of such medication.
  3. The legal prescribing ability of midwives must be addressed to fully equip them to provide first trimester TOP services, especially in the rural areas. Commencement of the SAMMDRA Act together with the long awaited regulations should ensure the required legal provision.
    1. General knowledge of health care personnel

Although personnel involved in the TOP services have a fair knowledge of the Act, the general knowledge of other health care personnel about the CTOP Act is limited.

Proposal:

  1. An information campaign aimed at health care workers should be launched.
  2. Partnerships between the State and NGO’s should be established to do this.
  3. Clear guidelines on referral for TOP and location of services must be made available to all health care services.
  1. TOP Services
    1. Access to TOP Services

2.1.1 TOP services

Although the availability of services has increased, access remains a problem especially in rural areas. According to various studies regional and district hospitals surveyed do provide TOP services. TOP services are more readily available in the regional than in district facilities and at urban compared to rural hospitals.

2.1.2 Transport

Clients often have to travel far to get to a service and once they get there, they are placed on a waiting list which often results in a situation where a second trimester abortion has to be done. The client must then be referred to another institution. This increases the problems of availability and financing of transport.

2.1.3 Legally required facilities

Reports have also been received of second trimester abortions being done at private institutions that do not have the legally required overnight facilities. Should these patients develop complications after the abortion, they go to the emergency unit of another institution, both public and private, which creates an additional patient load at that institution.

Proposal:

  1. Budget allocations should be adequate to provide for sufficient staff and equipment for institutions to provide TOP services.
  2. Employees working in the rural/underserved areas should receive an incentive to attract and retain them to these areas.
  3. Facilities, trained staff and services should be made more readily available at primary health care level.
  4. Transport opportunities and possibilities to enable access to services should be created and/or negotiated with both the health services and the community.
  5. TOP teams could be established to visit clinics on a regular and rotational basis to perform TOPs.
    1. Analgesia and pain control

Analgesia and pain control has been identified as a problematic area. Reports received range from services not providing any analgesia or pain control during TOP to reports received on the dangers of analgesia that could be associated with coma.

Proposal:

  1. A survey needs to be done in both the public and private sector to determine the current as well as the best practices for analgesia and pain control.
  2. National policies and protocols should be developed on the use of analgesia during TOP. If already developed they must be made known by the users.
  3. TOP trained midwives must be legally enabled to prescribe medication to ensure adequate analgesia and pain control during TOP, especially in the rural areas where the midwives do not have a medical practitioner nearby. Commencement of the SAMMDRA Act together with the relevant regulations should provide the required legal provision.
    1. Private sector services.
    2. 2.3.1 Fees

      Most private institutions are licensed to provide TOP services. Accessibility to private institutions appear to be easier. Some medical aid companies do financially support a predetermined number of TOPs.

      2.3.2 Non-disclosure

      Reports have been received that private specialist gyneacologists do admit clients for D & C’s which some times turns out to be a termination of pregnancy. Although nurses may be reasonably sure in some cases that it is a TOP, they are unsure about their role and responsibilities in these circumstances. The biggest concerns expressed are that:

    3. the scrub nurse may have indicated her unwillingness to participate in TOP and are now tricked into a situation where she does not really have a choice in the matter, and
    4. the client may miss an opportunity to be counselled.

Proposal:

  1. An information campaign be launched on the legal requirements of TOP services.
  2. This campaign be focused on the rights and responsibilities of both the client and the health care personnel.
    1. Counselling services for clients

Counselling services for clients are not adequate. Reports have been received of instances where no pre-counselling is done or in some instances where counselling is done in a group. In some cases counselling consists only of telling the client what the procedure will entail. Post-counselling is more often not performed, also because clients do not come back for such sessions.

This is not an acceptable situation. Reasons provided for these arrangements are mainly based on a lack of sufficient staff to run and deliver the services. Client reasons for not attending post-counselling is mainly lack of transport and financial constraints to get to the facilities.

Proposal:

  1. Human resource plans with sufficient staff: patient ratios must be developed and applied in the TOP services.
  2. Personnel other than midwives be trained and involved in the counselling sessions.
  3. Consideration be given to provide home-care services for post-counselling to prevent clients not coming back for these sessions due to financial constraints. This will require that a wider range of nurses and midwives (or other suitable health care practitioners) and NGO’s be utilized to deliver such a service.
  1. Consumers of services
    1. Lack of knowledge

The public lack knowledge of the CTOP Act and the services available for termination of pregnancy which is a matter for concern. All communication and education campaigns should be based on strategies accommodating the cultural and religious nuances and needs of various groups and the different provinces.

Proposal:

  1. Public education focussed at women and their right to TOP.
  2. Education campaigns also be specifically targeted at the youth. Youth sexuality education is a priority.
  3. Education of the public be done by way of pamphlets and media adverts.
  4. Education also be done via the printed media and the television and radio.
  5. Communication with the public on this issue also be commenced through popular magazines and journals.
    1. Maternal deaths

Maternal deaths resulting from back streets TOP are still too high. One of the aims of the CTOP Act is to reduce and eventually eliminate maternal deaths due to unsafe abortions. An additional piece of legislation in support of the improvement of maternal health made maternal deaths notifiable by law. Death due to pregnancy related sepsis, including septic abortion, was one of the top 5 causes of maternal death indicated in the first report on maternal deaths. The majority of these abortion deaths occurred in the second trimester.

Proposal:

Implementation of the National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD) recommendations which are included in the following suggestions:

  1. Public education focussed at women and their right to TOP.
  2. Development of services for both first and second trimester TOPs in areas where the audit indicated deficiencies.
  3. Pro-active development by the national and provincial Departments of Health of more first trimester TOP services at primary level and second trimester services at more secondary hospitals.
  4. Education and training of midwives for TOP services should be accelerated.
  5. The Act should be amended to enable other nurses, such as those doing family planning, to also offer TOP services.
  6. Consideration should be given to establish partnerships with NGO’s to provide training for both first and second trimester training in both the public and private sector.
    1. Attitude of staff

Teenage clients attending the services are quite outspoken about the disapproval that they experience from most health care workers. Media reports and some research projects have also indicated that the attitude of health care workers in general is not experienced as supportive to clients. This results in clients withdrawing and becoming unwilling to use the services available.

Reports on the staff in TOP services are, however, positive. Some of the health care workers providing TOP services appear to be less open to the idea of minors having free access without the consent of their parents or guardians.

Proposal:

  1. Value clarification workshops for all the staff in institutions where TOP is available can contribute to a more supportive attitude amongst the staff for each other and the client.
  2. Public education focussed at women and their right to TOP.
    1. Fragmented services

Fragmented services for other issues related to TOP, such as contraception and treatment for sexually transmitted diseases, are experienced as problematic by consumers of the service as they meet with a different person on every occasion and often have to come back on another day for service delivery.

Proposal:

  1. Provision of a one stop service for clients where TOP services are linked in some way with other services providing treatment for sexually transmitted diseases and contraception.
  2. The Act should be amended to enable other nurses, such as those doing family planning, to also offer TOP services.

CONCLUSION

It is clear from the discussion around the abovementioned issues that an information/education campaign focused on both the public and the health care workers, are the main feature for facilitating change. Much more work needs to be done to ensure that people understand their rights under the CTOP Act and how the health system works to provide access to termination of pregnancy. Much more work needs to be done to build health worker understanding of why women resort to abortions and their roles and rights in implementing this law.

The second important issue is the provision of sufficient, well trained midwives and nurses to deliver the services. Equally important is then adequate support and counselling services for the personnel involved in TOP services to ensure mental health and prevent burn out. Without enough and well motivated personnel with adequate training, there can be no effective service delivery.

Lastly but not least we call upon the Provincial Departments of Health to protect midwives and nurses who are being victimised for fulfilling the wishes of the clients.

RESOURCES

  1. ANONYMOUS 2000: Interviews with nurses and midwives employed in institutions offering termination of pregnancy services conducted during 3May – 2 June 2000.
  2. DENOSA 1997: A National Survey of South African Nurses. DENOSA: Pretoria.
  3. GMEINER, AC; VAN WYK S; POGGENPOEL M & MYBURGH CPH 2000: Support for nurses directly involved with women who choose to terminate a pregnancy. Curationis 23(1):70 –78. March 2000.
  4. HEALTH SYSTEMS TRUST 1998: South African Health Review 1998. Health Systems Trust: Durban. December 1998.
  5. NATIONAL COMMITTEE ON CONFIDENTIAL ENQUIRIES INTO MATERNAL DEATHS (NCCEMD) 1999: Saving Mothers. Report on Confidential Enquiries into Maternal Deaths in South Africa 1998. First Report. Department of Health: Pretoria.
  6. RESEARCH FORUM (13th: May 2000: RAU, Johannesburg).
  7. REPRODUCTIVE RIGHTS ALLIANCE 1999: BAROMETER. Towards ensuring access to Reproductive Choice. Volume 3. December 1999.
  8. VARKEY SJ & FONN S 1999: How far are we? Assessing the implementation of abortion services: A review of literature and work in progress. Women’s Health Project: Johannesburg. September 1999.