The Reproductive Rights Alliance (RRA) is a national alliance of organizations committed to creating and promoting reproductive rights, and specifically the rights of women to freedom of reproductive choices.

The RRA strives to play a supportive, catalytic role in:

• Providing information
• Mobilising people and resources
• Lobbying government
• Monitoring legislation on reproductive rights

One of the aspects of implementation is the monitoring of the service. The RRA collates information and disseminates this through the production of the publication Barometer, which has been used locally and internationally. Our monitoring efforts focus on the extent to which implementation is taking place, presenting the barriers to access and solutions to these.

Implementation

The RRA acknowledges that the introduction of the CTOPA has succeeded in increasing the availability of a service previously denied to the majority of South African women. Under the 1975 Abortion and Sterilization Act, 66% of women who accessed safe and legal terminations of pregnancy were white, while research carried out by the Medical Research Council showed that 99% of women who were getting sick or dying from back-street abortions were black. The legislation is saving the lives of South African women.

Implementation of this legislation has presented many challenges and the CTOPA is not unique in this regard. The health system is being transformed from a service for a privileged few to one for the entire population of South Africa. Among other things transformation aims to address the shamefully high maternal mortality figures that existed among black South Africans when the ANC came to power in 1994.

A recently published report by the Centre for Health Policy on financing health reform, which aims to produce equity in the health care system also cited staff attitudes and disapproval of free health care for pregnant women and children under six, as being a barrier to effective implementation.

The RRA does not deny that there are problems unique to implementing TOP services. However these problems are not unique to South Africa. A 1997 report in the United Kingdom reviewing 20 years of abortion reform in that country identified problems still existing with implementation. It is significant that even within a health service that is not totally transforming itself or faced with severe resource constraints challenges remain.

The World Health Organisation and other internationally respected bodies have been telling us that unsafe abortion is one of the major causes of maternal death worldwide for many years. Organisations such a UNICEF have been calling for access to safe and legal terminations because they acknowledge the large number of children orphaned by their mothers dying from back street abortions. Internationally the trend is towards legalising termination of pregnancy.

We want to congratulate the previous and present Minister of Health, as well as the members of this Committee for having the courage to pass the Choice on Termination of Pregnancy Act, even when they knew that this would open them to attack.

As well as showing a commitment to fighting unnecessary high levels of maternal mortality, the Choice on Termination of Pregnancy Act also recognises the present government’s commitment and respect of women’s rights enshrined in the constitution.

Under the previous legislation it was doctors, psychiatrists and judges who were making decisions about women’s lives and health. Now women themselves can make those decisions. Women have to live with the consequence of their decisions, so they should be the ones to make them. Women who have been raped or abused no longer have to go before a judge and be interrogated on what happened to them in order to access TOP services. They can now access safe and legal terminations on request.

While acknowledging that implementation is a process, and that both the National Department of Health, and the Provincial Departments of Health have made significant progress, we cannot deny that challenges to implementation still exist and a lot of work needs to be done to address them.

In this submission it is impossible to cover all the issues raised in these hearings. The following are areas that the RRA believe need special attention.

Lack of decentralization to PHC Levels:

• Services are mainly available at hospital level and therefore inaccessible to women, particularly in rural areas. As noted in the submission from the Reproductive Health Research Unit, many women live long distances from the nearest designated TOP centre.
• Reports that Barometer and the RRA office have received from the provinces indicate that plans to decentralise to primary health care centres are being developed. These plans need to be implemented.

Lack of trained staff has been identified as one of the problems facing those trying to decentralise TOP services, this end we would call for training in doing MVA to be incorporated into basic training for all Doctors and Nurses. As we heard in the previous submission from the Abortion Care Programme that some provinces have carried out provincial levels of training, we would urge all provinces to do so.

We have received reports from the provinces and from midwifes themselves that hospital management and matrons are sometimes indicating to Provinces that there is no one willing to be trained in MVA techniques, meanwhile there are some midwifes who are prepared. We would suggest that when recruiting midwives for the training the provincial organisers contact the midwives themselves, and do not rely on reports from hospital management.

• At PHC level, TOP services should be integrated with other services including contraceptive services

Private Sector Service Provision

• Whilst recognising the contribution private practitioners have made to implementation, these services remain inaccessible for the majority of South African women and so should never be seen as an alternative to increasing access in the public sector.
• We feel that tighter regulation of the private sector is needed to ensure quality and affordable TOP services. Private facilities must realise that their designated status can be taken away if they are not complying with regulations and that those that are not designated can be prosecuted.

Provinces must ensure that members of the public and medical professionals in the public sector who deal with the results of badly performed TOPs know where to lodge complaints, and that these complaints are investigated.

As was suggested by Dr Nsengani and in other submissions we feel that GPs have a role to play in providing TOP services. Research carried out on the treatment of STDs by the Centre for Health Policy indicated that many people would go to private practitioners when they are concerned about issues of confidentiality.

The CHP research found that GPs treatment of STDs was in many cases not ideal, and subsequently they have embarked on training courses for GPs. We feel that this is a model that could be used by people implementing TOP services. GPs need to be trained on the use of drugs and techniques so that they can play a supportive role in providing the service. GPs should also be reminded in their training that it is not acceptable to take advantage of women by charging them exorbitant rates.

2nd Trimester Terminations

• The high level of demand for 2nd trimester terminations is a reflection of inaccessibility to 1st trimester termination, distances to services and lack of information;
• Given the financial cost , the emotional burden and medical risk of 2nd trimester terminations, we recommend basic information on one’s fertility period, early signs of pregnancy and availability of pregnancy testing at PHC levels and increased access to 1st trimester terminations;

However as was stated by Dr Heather Brown of the Reproductive Health Research Unit there will always be some cases of women who need 2nd trimester services, and work must be done to ensure that these services are available.

Inter-sectorial collaboration

We believe that various stakeholders have a responsibility in this respect:

• Legislators can play an important role in community education by harnessing community support for the legislation;
• Researchers should continue to innovate and document the extent of implementation;
• Rights-based organisations should ensure that women’s reproductive rights are upheld through the implementation of the Act;
• Civil society structures in partnership with government should focus on education and information provision;
• Professional bodies should be vocal about their support for the implementation of abortion;

Cytotec/Misoprostal

• We recognise that the Department of Health and the Medical Control Council have been working hard to register this drug and that registration is in the pipeline.The National TOP Advisory Committee must now assemble a panel of experts to develop guidelines around use of this drug. These guidelines should strongly discourage over-the-counter dispensing of this drug. The registration of this drug or a generic equivalent by the MCC is imperative and long overdue. The Department of Health should lobby for this to be addressed as a matter of urgency;
• Education of GPs and pharmacists on the use of cytotec;
• Operational research should be carried out to determine whether the international research on medical abortificients such as RU486 could be applied in practice in South Africa to assist in the decentralisation of services

Conscientious Objection

• The submission from the Women’s Legal Centre best dealt with these issues. The RRA suggests that the National and Provincial Departments of Health study that submission carefully, and produce guidelines for people managing TOP services.

While we respect the right of health care workers not to perform TOPs except in medical emergencies, we feel that they have an obligation to refer women. In areas where there is a shortage of health personnel, willingness to do TOPs should be included in job descriptions and listed as an inherent requirement of the job.

Support for Health Workers

Numerous submissions have reported the need for support of health care workers providing the service. The RRA suggests that there are many ways of doing this, and that the same model might not be ideal for all provinces. Options such as setting up a hotline similar to the one that Lifeline has for its staff should be investigated.

We urge all parliamentarians and members of the NCOP to visit centres providing TOP services in their constituencies to show high level support for the services and the dedication of those providing them.

There are also committed people in provincial health departments doing their best to manage and decentralise TOP services. These people also need support from parliamentarians. The RRA Office can supply parliamentarians with any information and contacts they may require.

Provincial health department managers must ensure that health care workers providing TOP services and experiencing negative reactions and abuse from colleagues and management personnel in their institutions are supported and action is taken against those who are discriminating against them;

• 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;
• 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.

Support for Women

• The RRA believes that the research conducted by clinical psychologist Sheila Faure needs to be further tested throughout the country, and then widely distributed;
• Tools suggested in her research should be considered when developing protocols around counselling;
• Partnerships with NGOs should be formed to increase capacity and expertise.

Access to Information

In 1998 the Department of Health with the assistance of the Medical Research Council carried out a large nationwide household study in which they asked women if they knew TOP services were available on request up until 12 weeks. The results clearly show that more work needs to done among some of the most disadvantaged groups in society to highlight the TOP services available to them.

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The RRA believes that this data reflects the need for community education. The National Department of Health, along with the Provincial Departments of Health, should draw on their own expertise as well as that of NGOs and CBOs in getting information across to women in rural and disadvantaged communities.

Moreover, all education around TOP services must be done within the broader context of reproductive health and women’s rights.

Conclusion

The RRA thanks the Portfolio Committee on Health for giving us the opportunity to work with them around these hearings.

We believe the hearings have provided a useful forum in which concerns and issues around the implementation of the legislation have been aired and that many useful recommendations have been produced.

We have particularly appreciated the wide range of submissions that have been made, from health care workers from almost all the provinces, people working in rural and urban areas, as well as academics, lawyers, community workers and activists.

What is important now is to take the process forward.