Submission by Marijke Alblas, Medical Practitioner, to the Parliamentary Portfolio Commission on Health regarding the Choice on Termination of Pregnancy Amendment Act, no 38 2004

I am a medical doctor, involved in the Termination of Pregnancy (TOP) Program. Since 7 years I have worked together with the WCDOH in setting up TOP services in the designated facilities, I assisted in training nurses and doctors in performing safe abortions and I have been performing second trimester (13 to 20 weeks) TOP’s throughout the WC province, as part of a roving team.

I would like to comment as an individual on the importance of accepting the Amendments to the CTOP Act.

I am in favour of keeping the Amendments as they are, because they can help to increase the accessibility of the TOP services to all women:

• It simplifies and can therefore accelerate the process of designation of facilities, since it can now be done at Provincial level.

Instead of the National Minister of Health, the Provincial MEC can determine which facility is fit for designation.

• It increases the pool of healthcare providers that can be trained in performing first trimester TOP’s.

Before the Amendment Act, only a trained nurse/ midwife was allowed to perform first trimester ( up to 12 weeks) abortions, now a trained registered nurse is also allowed to perform these procedures. Before 2004, some registered nurses showed interest to be trained, but it was not legal. Since the acceptance of the Amendment Act we have trained several registered nurses and they are performing the first trimester procedures just as well as the midwives have been doing.

• By allowing 24- hour Maternity Services to perform the first trimester procedures without applying for designation

These Units don’t have to go through the approval procedure from the MEC, if they comply with the requirements stated in the Amendment Act.

With increasing the accessibility, we can help women to have their terminations earlier in pregnancy. While a termination of pregnancy is a safe and simple procedure (the likelihood of dying as a result of an abortion performed with modern safe methods is no more than one per 100.000 procedures, in Sub Saharan Africa however, where abortions are not legal 680 women are dying per 100 000 abortions). But safe abortions are especially safe early in pregnancy. The further the pregnancy is advanced the more risky the procedure becomes: the chances of complications grow by the week. Therefore more accessible services for early abortion can save many women’s lives and avoid the substantial costs of treating preventable complications of unsafe abortion.

As a doctor involved in the TOP services, I have seen many women requesting a TOP, who are already in the second trimester of their pregnancy.

There are several reasons for this late coming:

• Women don’t recognize the signs of pregnancy:

o some women keep on having their periods while already pregnant

o women using the 3 month injection as a contraceptive method often stop having their periods. When they go too late for the next injection and get pregnant, they don’t notice it immediately

o some women/ young girls don’t know their bodies well enough

• Some women don’t know where a designated TOP facility is
• Some don’t even know that a termination of pregnancy is legal in S.A.
• Many women are very scared to discuss the topic with anyone, it is a taboo subject
• Not all designated facilities are functioning: especially in the more rural areas, women still have to travel far and transport is a problemà here in the Western Cape we see many women coming for a TOP from the Eastern Cape, because they couldn’t find help there, but by the time they come here, they are often in the second trimester of their pregnancy or even too far (> than 20 weeks).
• Some health facilities still have waiting lists, so they push women into the second trimester

The result is that almost 25 % of the women with unwanted pregnancies come in the second trimester of their pregnancy and this poses an enormous problem for the health services:

• MVA (manual vacuum aspiration) used for first trimester procedures are simple and cheap (outpatient) procedures and can be done by trained nurse-midwives. Second trimester terminations are more complicated and costly for the health system (has to be done by a doctor, longer lasting procedure, it often involves occupation of expensive hospital beds)
• few doctors are willing to be involved in terminating a second trimester pregnancy
• many of the ancillary staff have problems in assisting with the second trimesters

It is therefore of the utmost importance to increase the accessibility and this makes it also possible for women to choose between a ‘for free’ service in a State faciltiy or an, often costly, private facility. With too few functioning State facilities women are forced to go to a private facility, because they don’t want to wait.

However, the reality is that many women who are in need of a TOP don’t have the means to go to a private facility. Most of the women I see in the State facilities are poor and their socio-economic status forces them to make the, often difficult, choice to terminate the pregnancy.

From the above it should be clear how important it is to increase the access to quality TOP services. And it should be without question that these services must be combined with a comprehensive contraceptive service, to prevent repeat abortions. Women should leave after the TOP procedure with the contraceptive method of their choice.

Many of the women who come with the request for an abortion did not use an effective family planning method. That is a matter of concern and we will have to give more attention to accessible and woman friendly comprehensive contraceptive services as well!

To summarize:

As an abortion provider I am in favour of the Amendments to the CTOP Act, because they have the ability to increase further access to the TOP services.

Our aim with increasing acces, is especially to reach women earlier in their pregnancy, so we can reduce the number of further advanced pregnancy terminations and also prevent unsafe, backstreet abortions.

Marijke Alblas, MD

P.O.Box 99

Observatory 7935

Cape Town

ADDENDUM:

We are pro-choiche because we don't want women to suffer any longer, we want to empower them, so they can make their own choices.

However others believe it is their right to stop women from having abortions, but in this way they are protecting their own conscience and the result is that others have to pay the price for their principles.

We can look at it this way:

When a woman finds herself pregnant due to violence and chooses an abortion, it is the violence that is the tragedy; the abortion is a blessing.

When a woman finds that the fetus she is carrying has anomalies incompatible with life, that it will not live and that she requires an abortion, often a late-term abortion, to protect her life, her health, or her fertility, it is the shattering of her hopes and dreams for that pregnancy that is the tragedy; the abortion is a blessing.

When a woman wants a child but can't afford one because she hasn't the education necessary for a sustainable job, or access to health care, or day care, or adequate food, it is the abysmal priorities of our nation, the lack of social supports, the absence of justice that are the tragedies; the abortion is a blessing.

And when a woman becomes pregnant within a loving, supportive, respectful relationship; has every option open to her; decides she does not wish to bear a child; and has access to a safe, affordable abortion, there is not a tragedy in sight -- only blessing. The ability to enjoy God's good gift of sexuality without compromising one's education, life's work, or ability to put to use God's gifts and call is simply blessing