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.