AIDE MEMOIRE - CTOP AMENDMENT ACT NOVEMBER 14, 2007

I am a chief specialist obstetrician and gynaecologist, a professor and head of the Department of Obstetrics and Gynaecology, Nelson R Mandela School of Medicine, Head of the School of Maternal, Child and Women's Health

A member of the National Committee for the Confidential Enquiry into Maternal Deaths A provincial assessor of maternal deaths in KwaZulu-Natal

A member of Council, College of Obstetricians and Gynaecologists (main certifying body for specialists in South Africa)

A member of Council, South African Society of Obstetricians and Gynaecologists (SASOG)

Adjunct Member of Faculty, Department of Maternal and Child Health, School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina Honorary Deacon (Barbee's Missionary Baptist Church, USA) and Lay Preacher (South Africa)

Former Chief Director, Maternal Child and Women's Health, National Department of Health, South Africa

1. The CTOP Act, 1996 is one of the most dramatic interventions of recent years in South Africa, and possibly in the world. Other countries are Romania after liberalisation of termination of pregnancy. Even With limited implementation, the CTOP implementation has resulted in morbidity and mortality among women. It has involved a change in mindset so that in rural areas there is some access to facilities for making choice about termination of pregnancy.

2. In our institution, King Edward VIII Hospital, there has been such a dramatic drop in the number of women with septic abortion that registrars are at risk of not seeing a case of septic shock from unsafe abortion during their training. From an average of 15 cases per 24 hours to 2 cases is a big drop!

3. The CTOP Act applies to the stopping pregnancy by means other than natural.

4. Abortion is traditionally defined as termination of pregnancy before 28 weeks. Twenty eight completed weeks is therefore defined as the start of the 3rd trimester. However this no longer applies as viability is lower than 28 weeks. It is considered that on average, in developed countries (or areas where there are advanced technologies), about 24 weeks is viable. However as stated in the SAMA submission, many of the babies born at these ages will die, and those remaining will have severe development disabilities or abnormalities.

5. Within the first 12 weeks, termination of pregnancy is performed in the interest of the physical, mental or social well being of the woman

6. Above 20 weeks, the pregnancy may be terminated in the interest of the woman or the foetus (baby). Termination of pregnancy therefore includes procedures such as induction of labour, hysterotomy and caesarean section.

7. Reasons for terminating a pregnancy in the interest of the foetus include the following common cases:

a. Severe placental insufficiency leading to intra-uterine growth restriction (IDGR)

b. Severe Pregnancy Induced Hypertension (pre-eclampsia)

c. Abruptio Placentae (separation of the placenta and bleeding)

d. Placenta praevia (placenta is in front of the presenting part of the baby)

e. Foetal distress nom various causes (in and out of pregnancy)

8. Reasons for terminating a pregnancy in the interest of the woman include the

following common situations:

a. Convulsions because of severe high blood pressure (eclampsia)

b. Bleeding because of abruptio placentae or placenta praevia

c. Cardiac disease

d. Renal failure

e. Previous caesarean section

In all the conditions above, the pregnancy is terminated before spontaneous onset of labour. The Act therefore allows the woman to make a decision about her body with regard to the outcome of pregnancy.

Tenninology Abortion and Pregnancy Termination

9. There is lack of unanimity in the medical sphere with regard to termination of pregnancy before viability. Viability itself is deemed to be attained at different gestational ages given the different environments. In developed countries, it is deemed to be as low as 22 weeks, while in developing countries, babies born before 30 weeks (1.5kg) will find it hard to survive. The word "Abortion" was used to define a pregnancy that ended before 28 completed weeks. However the Principal Act recognises a lower limit for potential viability (20 completed weeks). The laws in the United Kingdom and United States of America have a higher gestational age, thus there will be abortions that are called "late abortion" or "partial births".

Conscientious objection

10. The Constitution covers conscientious objection. This therefore makes it unnecessary to include it specifically in the principal Act. There are various situations for which there would be conscientious objection. Some examples are the following:

a. Sex change operation

b. Giving blood for someone bleeding

c. Treating men who have Sexually Transmitted Infection nom activities

outside the marital bed

d. Treating commercial sex workers, etc

11. There are also conditions that people would object to, even in cases of emergency. It is strange that there is no objection to health workers managing attempted suicide, drunken drivers injured in Motor Vehicle Accidents. Currently it is permissible not to assist a person in a case of emergency. Both the South African Nursing Council (SANC) and the Health Professions Council of South Africa (HPCSA) consider a bleeding woman (whatever the cause of the bleeding) an emergency. Any health worker neglecting or refusing to assist such a woman will be guilty of unprofessional conduct.

12. It is my belief that conscientious objection clauses will need to be included in each of our laws, therefore making the Constitution of our country' redundant. This we cannot ourselves to do clandestinely.

Counselling

13. The present provisions for counselling are adequate. Where such services are available, it is recommended. However note must be taken that counselling takes various forms under various conditions. Within rural communities, relatives, neighbours and friends provide support for the decision making. This however is not considered counselling in the orthodox medical and sociological environment. Yet this may be more effective than what any "professional" counselling offers. The least that the person must know is the advantages, disadvantages and process of the termination of pregnancy attendant to the intervention.

14. There is tendency on the part of health workers trying to dissuade women from chosing termination of pregnancy to perform detailed ultrasound examination, describing to the woman the various parts of the foetus. This disregards the recommendations of many national and international guidelines with regard to the use of ultrasound, as this technology has not been shown to be without adverse effects. Certainly prolonged exposure to ultrasound waves without justification is discouraged

Registered nurses

15. The training of registered nurses will include the provision of contraceptive technologies. This aspect of reproductive services is often neglected and the added number of workers competent in this aspect will improve access to prevention of unwanted pregnancies. The training will entail skills assessments.

16. It is my persuasion that TOP providers should be included in the category for scarce resources. There must also be a structured support mechanism for the health workers involved in the termination of pregnancy below 20 weeks of pregnancy. Failure to address this support will deprive women of an opportunity to make a choice with regard to their pregnancies.