SUBMISSION REGARDING THE CHOICE ON TERMINATION OF
PREGNANCY AMENDMENT ACT (CTOPA) No 38, 2004
Marion Stevens
Project Manager
Treatment Monitor
Health Systems Trust
www.hst.org.za
Submission
endorsed by:
SUMMARY: FOCUS OF THIS SUBMISSION AND UNIQUE CONTRIBUTION OF THE HEALTH SYSTEMS
TRUST
1. The focus of this submission will respect the
bounds of the parameters of the Constitutional Judgement which noted that there
should be wider consultation on the CTOPA Act as opposed to other substantive
matters concerning areas related to abortion.
2. The CTOPA Act was enacted to assist the health
system in providing better access to high-quality termination of pregnancy
services. It has been successful in doing do and in decreasing abortion-related
maternal mortality and morbidity.
3. Maternal mortality and morbidity is understood currently
to be caused mainly by AIDS and related opportunistic infections. The CTOPA has
played a valuable role and should remain in place to ensure that unsafe
abortion does not again increase as a cause of maternal mortality and
morbidity, particularly among HIV-positive women. In continuing to transform
and build the health system, high-quality abortion services need to form part
of integrated sexual and reproductive health services which include HIV/AIDS
services through a continuum of care.
4. The Health Systems Trust has worked for over 15
years closely with government in transforming and building a health system that
is oriented towards accessible, equitable and high-quality services. Our
various programmes in research, health information, district development and
health policy have served to support the country and government. We are a
national organisation and, as such, our voice brings a representative
perspective. Our annual South African Health Review (SAHR) in 2006 focused on
Maternal, Child and Women’s Health and provided valuable empirical information
to inform policy.
In introducing our submission it is important to
explore the parameters of the Constitutional Court ruling in August 2006 on the
CTOPA Act. The provisions of the Choice on Termination of Pregnancy Act, 96 of
1996 are not in dispute. The substance of the provisions within the Choice on
Termination of Pregnancy Amendment Act, 38 of 2004 are also not in dispute.
Rather, it is a technical judgement ruling which held that the NCOP needed to
include wider public participation. As such the content of this submission will
not engage with other issues related to abortion, but primarily on the CTOPA
Act orientation, that of increasing access to services. It should be noted that
there was significant consultation and public participation on the CTOP Act
before it was enacted[1].
The reduction of morbidity and mortality of women
with regards to childbirth is one of the ten strategic objectives of the
National Department of Health. The provision within the CTOPA Act is one of
many mechanisms put in place to reduce illness and death in women.
As noted by the Minister of Health, Dr Manto
Tshabalala Msimang, ‘We all know that maternal mortality from unsafe abortion
is a social injustice and a violation of the human rights of women’[2].
The Department of Health has been concerned by the inaccessibility and
unavailability of safe and legal termination of pregnancy services in most
parts of the country, more especially in the rural areas.
The CTOPA was developed in an attempt to deal with
these issues and the specific provisions and advantages have specifically been
to:
The impact of the CTOPA legislation has had a
profound impact in increasing access and decreasing abortion-related maternal
morbidity and mortality. In 1994 the Medical Research Council (MRC) found that
44 686 women presented with incomplete abortions at public health facilities
and that some 425 women died of unsafe abortions.[4]
An overwhelming majority of 99% of these women were black, indicating the
social injustice of this situation. The State was calculated to have spent some
R18 700 000[5] on
treatment of complications arising from ‘backstreet’ abortions, which were
usually presented in the form of sepsis, haemorrhage, infertility and death.
The provision of the CTOPA in providing for greater access to high-quality
abortion services has resulted in reduced maternal morbidity and mortality.
After only three years of implementation, maternal deaths due to unsafe
abortions were reduced by 91% in 2006[6].
Maternal mortality and morbidity is understood
currently to be caused mainly by AIDS and related opportunistic infections. The
Fourth Interim Confidential Maternal Enquiry report, which covers the years
1998 to 2003, showed that there was an increase in deaths from 676 to 1 154
during this period; the causes shifted to non-pregnancy-related infections
resulting from HIV-related diseases[7].
The CTOPA has thus played a valuable role and should remain in place to ensure
that unsafe abortion does not again increase as a cause of maternal mortality
and morbidity, particularly among HIV-positive women. In continuing to
transform and build the health system, and to maintain and increase access to
safe termination of pregnancy, high-quality abortion services need to form part
of integrated sexual and reproductive health services which include HIV/AIDS
services through a continuum of care.
The CTOPA, in greatly eliminating abortion-related
mortality and morbidity, has decreased this particular burden on the health
system. HIV/AIDS presents another challenge in terms of maternal health; in
addition to measures to prevent perinatal transmission and to offer
HIV-positive women high-quality antenatal and post-natal care, the option of
voluntary abortion should be offered as part of the continuum of care for
HIV/AIDS care. Presently these services are not integrated and HIV-pregnant
women are not offered a choice to terminate unwanted pregnancies. Care must be
given that women are afforded an unreserved choice to terminate or continue
their pregnancy.
The CTOPA Act was enacted to assist the health system
in providing better access to high-quality termination of pregnancy services.
It has been successful in doing do, in decreasing abortion-related maternal
mortality and morbidity. We strongly advocate for maintenance of this Act in
our legal system. We also recommend that the provisions of the Act be widely
disseminated, not only to health-system managers and personnel, but also to
women through community-based outreach so that they are aware of measures that
will increase their access to safe legal abortion.
SUBMISSION COMPILED BY:
Marion Stevens
Project Manager
Treatment Monitor
Health Systems Trust
ATTACHED SUPPORTING DOCUMENTS
SAHR
Vekemans, M. and de Silva, U. HIV-Positive Women and
their right to choose. Entre Nous 59 2005. pg 17-20 WHO.
.
[1] Klugman, B., Stevens, M and Arends, K. ‘ Developing Women’s Health Policy in South Africa from the Grassroots. Reproductive Health Matters. 6, November 1995 and Klugman, B . and Budlender, D. (eds) Advocating for Abortion Access: Eleven Country Studies, The Johannesburg Initiative, Women’s Health Project, School of Public Health, University of the Wirtwatersrand, Johannesburg, 2001.
[2] Department of Health and IPAS. 2003. National Strategic Plan for the Implementation of the Choice of Termination of Pregnancy Act 92, 1996, as amended.
[3] Schneider, H., D. Blaauw, L. Gilson, N. Chabikuli, and J. Goudge. 2006. “Health Systems and Access to Antiretroviral Drugs for HIV in Southern Africa: Service Delivery and Human Resources Challenges.” Reprod Health Matters 14(27):12-23.
[4] Rees H, Katzenellenbogen J, Shabodien R, Jewkes R, Fawcus S, McIntyre J et al. The Epidemiology of Incomplete Abortion in South Africa. South African Medical Journal 1997: 87; 432-438.
[5] Ditto
[6] Department of Health. 2006. Confidential Maternal Deaths Notification Report.
[7] National Committee for Confidential Enquires into Maternal Deaths. Fourth Interim Report on Confidential Enquiries into Maternal Deaths in South Africa, Changing Patters in Maternal Death 1998-2003.