NATIONAL YOUTH COMMISSION SUBMISSION TO: PORTFOLIO COMMITTEE ON HEALTH: CHOICE ON TERMINATION OF PREGNANCY ACT OF 1996
1. INTRODUCTION:
The National Youth Commission wishes to recognise the groundbreaking role that the Health Department has played in the legislation of the Termination of Pregnancy Act of 1996. We fully endorse the recognition, through this Act, that the Constitution protects the Right of persons to make decisions concerning reproduction and to security in and control over their bodies. The National Youth Policy recognises the need for policies and programmes which deal specifically with health. We also recognise that in dealing with youth health particular attention needs to be given to the issue of gender. Patriarchal attitudes, structures and procedures often disadvantage women, creating power relations within which young 'Women are often found vulnerable and often have less power over their bodies than men. We therefore wish to submit a number of issues for debate / discussion at the over sight hearings on the Termination Of Pregnancy Act organised by the Portfolio Committee and the Reproductive Rights Alliance.
2. ISSUES:
2.1 Information Young women often do not have access to information regarding their right to termination of pregnancy. The government national survey in 1998 showed that only 53% of women knew that they can get TOP on request up to 12 weeks, and even fewer (40,1%) aged 15 - 19 knew about the new legislation. Teenage pregnancy is still a problem in South Africa and many young women still drop out of school because of this, affecting their whole future. Youth experiencing unwanted pregnancy often have no guarantee of confidentiality, especially in a pre- counselling situation. In rural areas this problem is compounded, resulting in a destructive cycle of disempowerment and poverty.
2.2 Access to service Clause 3 of the Act stipulates places where surgical termination of pregnancy may take place as designated by the Minister through a Gazette. Most, young people do not have access to Gazettes therefore again are disadvantaged in terms of how they could access the service. They also would not necessarily want to go to the nearest health facility to get the relevant information as this might have implications in terms of confidentiality. Secondly, youth in most rural areas, even with the relevant information might not have access as most of these facilities are based in more urban areas. Accessing the service would therefore mean travelling to the nearest facility, which would have financial implications. In the more rural provinces TOP is sometimes not even considered as an option, given the distances to the nearest facility. It is also significant that women in the rural provinces (Northern Province, Eastern Cape and Northern Cape) are the least informed about TOP legislation.
Another urgent issue to contemplate is the extent of the willingness of medical practitioners to perform TOP (doctors and midwives). A number of these people have indicated their unease in terms of performing the procedure due to their own individual beliefs. This has a particular impact on access to service where medical facilities and practitioners are scarce, again mostly in less urban areas. It would be advisable to analyse statistics on unwanted (if there are any) or teenage pregnancies and compare that to the availability of the TOP service'.
2.3 Pregnancy resulting from rape or incest Clause 2(b)(iii) makes provision for termination of pregnancy under these conditions. Given the fact that rape and abuse are so common in this country, much more needs to be done in support of women who fall pregnant in this manner. There needs to be certain mechanisms put in place making die termination as trauma free as possible for the woman involved. Cases have been reported where the woman has chosen not to report the rape and experienced attitude problems with health workers not 'believing' her version when she requested a termination. In the case of incest, this almost always is tied to specific power relations in the incestuous relationship, resulting in disempowerment of the woman/ girl involved. The Act obviously cannot deal with fills in detail, but unless the issue is addressed more holistically very few women/ girls in this category can be assisted.
2.4 Counselling and Information Clauses 4 and 6 apply. Cases have been reported where counselling was not nondirective, but biased towards non-termination of die pregnancy, playing on the emotional vulnerability of women contemplating termination of pregnancy. It has also been stressed by the representative for disabled youth on the Commission that counselling for expecting young disabled women are mostly directed towards termination because of a perceived inability in young disabled women to care for the baby. Most women would want information on their rights under this Act, without necessarily engaging with die health system or a health facility directly. Most lay people are reasonably intimidated by the medical establishment and would not necessarily confront them on their advice or verdicts. Youth are obviously even more vulnerable.
2.5 Minor Consent Clause 5(3) refers. Practitioners mostly refer a minor for consultation as indicated in the first section of this clause. This is often experienced negatively by youth in this position, which leads to time delays as they try to comply with the requirement. Given the fact that a young woman or a minor experiencing an unwanted pregnancy is mostly fearful, there is often a delay with regards to the first consultation/ engagement. With the system. These time delays often lead to further complication in terms of the time frames for TOP and the minor does not return. Minors are mostly not informed about their right to choose not to consult family of friends and that a TOP cannot be denied because of this. The clauses on consent should also stress especially disabled women's choice not to terminate the pregnancy without pressure.
2.6 Legal recourse Clauses 7(5) and 10(2) apply. Although there is appreciation for the inclusion of clause 10 in the Act, there is no mechanism included in clause 10 (2) which will guarantee continued confidentiality for the woman who wishes to, take legal action against any person or institution guilty of obstruction. The very nature of the legal process involved could result-in the loss of confidentiality, thus dissuading most women from taking this route given the intensely private nature of the termination of pregnancy issue.
3. RECOMMENDATIONS:
· On issues of information That a broader campaign be launched in order to inform women and young girls about their rights under this Act. That information leaflets contain practical first steps that could be taken by women experiencing unwanted pregnancies and contemplating termination. That relevant information on TOP be forwarded to all currently existing helplines, or a specific TOP helpline be established for a period of at least three years. That distribution points for information on TOP (e.g. leaflets) be distributed also to centres outside of a health facility (e.g. schools, libraries, retail stores)
· On Access to service points That access to rural areas be increased. That a survey be done to establish the correlation between access points, ruralness, and unwanted or teenage pregnancies. That an anonymous (region / area specific) survey be done amongst medical practitioners which will test attitudes, opinions, empathic behaviour, etc. The aim with all of these surveys would be to assess the nature and extent of availability of the TOP service, for specific intervention programmes which will either increase -access or training or empathic attitude. That mechanisms be found to prevent waiting lists from being too long, resulting in further legal and medical procedural complications.
· On TOP for rape or incest survivors That specific training be given to practitioners on assistance to women / girl children who find themselves in this position. That the medical procedure be as speedy and painless as possible - this refers specifically to the manual vacuum aspiration procedure which is widely used, but which is a painful and traumatic procedure . Alternatively, methods of pain relief need to be put in place including making the environment as friendly and supportive as possible throughout the procedure. That partnerships be forged between the Health Department, other stakeholders in the Health Field, Youth Commission, Education Department, Welfare Dept. (who are often firstly aware of incest cases), Justice Department and the South African Police Service in order to offer a more supportive environment to survivors of rape and incest and information to children at school.
· On minor consent and youth -friendly access and counselling That mechanisms are adopted to ensure that minors are fully informed of their rights and can exercise the option of non-consultation in a supportive,non-pressurising environment or be encouraged to exercise die consultation option linked to specific time frames for return to the institution. That pre- and post counselling be done by properly trained peers in the youth sector, who can either be appointed part-time in a 'job-creation for youth type project or through a youth service type project. A model that could be looked at is the ' Health Centre' in Kimberley in the North-Cape province This is a partnership programme between a number of stakeholders, led by the Health Department, aimed at
providing specific reproductive health services -including TOP counselling and referral -mainly to youth. All personnel at the centre dealing directly with youth are in the youth category. The Provincial Youth Commission was included in the appointment process, thus contributing towards ensuring that personnel are sensitive to youth concerns If such a model can be extended and replicated with inclusion of on-site TOP service, it would be even more effective in terms of holistic service delivery to the youth. That community health workers be re-trained effectively in order to sympathetically deal with the health needs of youth. This is of cardinal importance if we want to encourage young people's faith in and usage of the public health system, which will in turn lead to a decrease in teenage pregnancies, better contraceptive usage among the youth, a decrease in STD's and ultimately a lessened vulnerability in terms if HIV/Aids.
On processes regarding legal recourse The preamble to the Act recognises the responsibility of the State to provide safe conditions under which the right of choice can be exercised without fear or harm The element of fear and vulnerability cannot be over-emphasised for a woman or girl child who might have to consider termination of pregnancy. This problem can be greatly reduced by some of the recommendations listed above. In eases where women might want legal recourse but wish to retain confidentiality, enabling mechanisms need to be found. Some mechanism could be provision for in-camera procedures.