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South Africa Changes Abortion Law
| Introduction | When the government of South Africa introduced its new Choice of Termination of Pregnancy Act in 1996, Dr. Harvey Ward, an obstetrician in Cape Town, warned legislators that the Act had been drafted without regard to the ability of existing medical facilities and personnel to cope with its demands. In addition to logistical problems associated with resources and training, he drew attention to the fact that a significant number of health care personnel would likely object to participation in abortion for reasons of conscience. "The Government would do well," he wrote, " to ensure that there are satisfactory answers before plunging the medical profession into a serious crisis by prematurely enacting this bill." Subsequently, Dr. Ward surveyed state doctors in the Western Cape to determine if they were willing to implement the new law. Much of the survey is now available on the Project site. |
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5 Kamassi Avenue, 20 April 1996. The Secretariat, Fax Number: 461-4339 Conscientious objection to participating in or performing abortions in the light of proposed legislation tabled before parliament for the current year 1996. Considerations and recommendations If the current Abortion and Sterilisation Act 1975 is changed to that envisaged by the Government, the effect of the influx of women seeking Abortion on demand under 14 weeks and selectively for pregnancies up to 24 weeks, on the existing services in the country has not been adequately estimated. There are a number of crucial factors worth considering: 1.All women seeking abortion will need to be assessed : a. History taken, physical
examination - taken by midwife/nurse/doctor 2.All women who will undergo an abortion require/will have to; a. Sign an informed consent
form: - doctor/midwife? If abortion on demand up to 14 weeks and selectively up to 24 weeks is to extended to South African women as a right, and is to be provided as envisaged at a primary care level it is critical for the government to ascertain whether or not the current complement of medical and associated personnel at the primary points of delivery are a. available and b. conscientiously prepared to provide these services. The government have steadfastly defended the individual's right to refuse to be involved in the abortion process yet should a key person in the "team" refuse to co-operate, the patient will inevitably have to be sent on/referred to another venue. Here she will undergo the same and this time with an entirely new set of staff, who are equally within their right to question the details and decide for themselves whether or not they wish to be involved with the procedure. Refusal by any member at this level will necessitate further referral and the issue becomes particularly complicated. Conscientious objection to involvement in abortions by full time personnel can foster a sort of "Us and Them" attitude and may serve to strain intra- and inter-departmental relationships . Understandably, persons having no objections would be required to perform extra work on behalf of colleagues in addition to their prescribed duties which would breed resentment. Another problem arises when personnel who formerly constituted an abortion team decide to object on conscientious grounds. The introduction of additional remuneration for providing an abortion service carries the stigma of Blood money for those so employed which further polarises service providers, and besides the government will lose the 'moral high ground' when it provides remuneration for those who will wilfully destroy members of the next generation on the grounds that they are not wanted and yet refuse to provide funds to help those indigent women who are infertile who indeed desperately wish to conceive, carry and parent children Does the government expect a full complement team to be available at all levels to provide an abortion service? If so, will the jobs at these facilities be reserved for personnel who are willing to provide such a service? If so, will disclosure of objections to abortions negatively discriminate against nurses, doctors and other health care providers? This would inevitably involve labour legislation as abortions would constitute only a small portion of the overall primary health care mandate. Would doctors and nurses wishing to qualify in the field of Obstetrics and Gynaecology be selected for training on the grounds that they did not object to performing abortions? The right to object to perform abortions is upheld but the price of refusal may mean unemployment or lack of promotion. Would this discrimination be constitutional? It is obvious from current referral patterns that many areas will not provide an abortion service on the grounds of objection. This will result in increasing referral to tertiary centres and an overwhelming load for their staff . It would be an impossible task to identify the need and adequately train the large numbers of personnel required for the performance of abortions in even the secondary level of health care facilities around the country, if the proposed law would be introduced in 1996. There are probably not enough facilities, and not enough trained or willing personnel currently employed by the State who are willing or even able to cope with the anticipated influx of women who would wish for and be eligible for an abortion under the proposed legislation. Before the government, passes any Bill in parliament allowing for the proposed relaxation of the Abortion Laws, serious consideration should be given to the following : 1.A comprehensive survey to assess the availability of trained and willing staff to provide an abortion service at a Primary level clinics and hospitals. 2.The legislation for use of misoprostol or RU 486 as a self administered preparation under GP or even pharmacist guidance to initiate a miscarriage. The aftermath as an inevitable or incomplete abortion may be managed at whichever level of health care is appropriate. Here a principle of "no questions asked " management is applied as for any patient with threatened or incomplete pregnancy loss. 3.The provision of designated clinics or conversion of certain units in secondary level hospitals with the employment of staff specifically for the purpose of performing abortions only. This would enable referrals to be centred and ensure that objectors can not be discriminated against when applying for training or teaching posts. These clinics can be staffed, administered and audited separately. The time to be proactive about this issue is here. Before any law is changed, teams willing to do abortions would have to be established and venues designated in anticipation. Clear management and referral protocols need to be formulated for and by each regional centre. Advertisements would have to be placed to recruit staff for these facilities and funds solicited from the Department of Health for the purpose. If no personnel can be found willing to staff such a clinic can the government then enshrine a constitutional right when none of its citizens will provide the means to accede to that right? Would they then have to import abortionists? If so, then where from and how acceptable would this be to the public? However, if support for the proposed legislation is indeed overwhelming as is claimed by some , then there should be no shortage of applicants. Should the Draft Constitution become ratified in May 1996 and these are considerations not taken into account, we may well find our facilities overwhelmed, our personnel dispirited and divided, and our existing services in disarray. signed, Dr.Harvey R.G.Ward 5 Kamassi Ave, 2 October 1996 From Fax Number:
021-5311488 Mr.Edzi Ramaite Dear Sir, Major problems with proposed New Abortion law. Before passing the proposed Termination of Pregnancy Act, the Government is advised to consider the following problems which if left unaddressed will threaten to disrupt the service and polarise the staff. The procedure at any gestational age is not simple and uncomplicated as any of those who are currently required to perform them knows. Trained midwives are proposed to be allowed to do this procedure. 1. Does this include the use of Ultrasound to accurately diagnose the presence and age/s of the fetus/es? Will machines be available at every facility operated by capable sonographers? The law and the procedure are both heavily dependant on accurate gestational ageing. 2. The administration of local analgesia for dilating the uterine cervix in the form of cervical or paracervical block is difficult. Current research suggests that it may be insufficient even in experienced hands. Does this imply that analgesia may have to be inadequate at times or will general anaesthesia be required to be on standby? If so, what back up services are expected? 3. Consent will legally be required for the procedure. Is consent from a minor, legal ,without the parental sanction? In the event of complication, transfer to another hospital, or further surgery, how can parents be kept uninformed? Consent is currently required for a minor to undergo evacuation of the uterus following an incomplete miscarriage. 4. In the event of complications, such as perforation of the uterus due to incorrect gestational ageing, or missing the fetus at suction evacuation, or profuse bleeding needing transferral and hysterectomy can the midwife be sued? If so, what is the opinion of Medical Defence associations and the South African Nursing Council? Are prospective trainees informed of this? 5. Conscientious objection: The Act provides for those who do not wish to participate in pregnancy termination to do so but the Government has not ascertained whether or not there are sufficient numbers of well-trained AND willing personnel at the institutions designated by the Minister. Current referral patterns suggest that there are very few practitioners who perform terminations even under current legislation outside State Hospitals. Has the Government surveyed State Hospital Staff to determine the extent of conscientious objection? This involves medical and nursing staff. What does the State do when no person willing to perform abortions can be found in a given region? If referral is needed ,who pays ? Will consent to perform abortions (or to train those who will) , be a prerequisite for employment in Public Service for obstetricians? Will students wishing to specialise in Obstetrics and Gynaecology be required to perform abortions as per the act in order to qualify? The Above questions are practical issues that will face the medical staff at point of service. The Government would do well to ensure that there are satisfactory answers before plunging the medical profession into a serious crisis by prematurely enacting this bill. Harvey Ward - Bsc (Med), MBChB,
DMCOG
5 Kamassi Avenue, 2 October 1996 From Fax
Number: 021-5311488 Mr.Edzi
Ramaite Dear Sir, Major problems with proposed New Abortion law. (Written Submission) Madame Speaker and elected members of the National Assembly of the Parliament of South Africa It is with appreciation that am afforded the opportunity of addressing you with my concerns regarding the proposed enactment of the Termination of Pregnancy Bill. Before passing the proposed Act, the Government is advised to consider the following problems which if unaddressed will threaten to disrupt the existing service and polarise staff. I believe that even more women will end up being injured , becoming infertile and have life threatening complications - certainly something this intended bill is being proposed to prevent. The abortion procedure at any gestational age is not simple or uncomplicated as anyone currently required to perform them knows. `Trained midwives’ are proposed to be allowed to do this procedure which introduces critical issues: 1. Does this include the use of Ultrasound to accurately diagnose the presence and age/s of the fetus/es? Will machines be available at every facility operated by capable sonographers? The law and the procedure are both heavily dependant on accurate gestational ageing. It is the experience of all midwives and doctors in the profession that confirmation of gestational age can be very difficult without sure knowledge of menstrual dates. Ultrasound examination is very useful but requires considerable skill. The cost of maintaining and securing such equipment at proposed clinics offers no mean challenge if today's levels of hospital theft prevail in the future. Even simple machines cost in the region of R70 000. 2. The administration of local analgesia for dilating the uterine cervix in the form of cervical or paracervical block is difficult. Current research suggests that it may be insufficient even in experienced hands. Does this imply that analgesia may just have to be `inadequate’ at times or will general anaesthesia be required to be on standby? If so, what back up services are expected? 3. Consent will legally be required for the procedure. Is consent from a minor, legal ,without the parental sanction? In the event of complication, transfer to another hospital, or further surgery, how can parents be kept uninformed? Consent is currently required for a minor to undergo evacuation of the uterus following an incomplete miscarriage. Could parents sue for wilful abduction or assault? 4. In the event of complications, such as perforation of the uterus , incorrect gestational ageing, missing the fetus at suction evacuation, fetal injury in unsuccessful abortions, or profuse bleeding requiring transfusion, transferral and/or hysterectomy due to operator incompetence, can the midwife be sued? Will she/he be required to take out medical insurance? If so, what is the opinion of Medical Defence associations and the South African Nursing Council? Are prospective trainees informed of this? 5. Conscientious objection: The Act provides for those who do not wish to participate in pregnancy termination to do so but the Government has not ascertained whether or not there are sufficient numbers of well-trained AND willing personnel at the institutions designated by the Minister. Current referral patterns suggest that there are very few practitioners who perform terminations even under current legislation outside State Hospitals. Has the Government surveyed State Hospital Staff to determine the extent of conscientious objection? This involves medical and nursing staff. What does the State do when no person willing to perform abortions can be found in a given region? Will consent to perform abortions (or to train those who will) , be a prerequisite for employment in Public Service for obstetricians? Will students wishing to specialise in Obstetrics and Gynaecology be required to perform abortions as per the act in order to qualify? 6.The premature passage of this law will as has happened in every other country liberalising its abortion laws, encourage a relaxation of vigilance to use contraception and result in an increase in the number of admissions daily to gynae firms on intake in Government hospitals. At present the national infrastructure does not have the facilities to cope with, the personnel willing or able to perform abortions as per the proposed act . The time to find out that the service cannot be provided is most certainly not after the right has been given legally to pregnant women. 7.The possible imprisonment of any person including vital service personnel, found guilty of “obstructing or failing to refer a woman eligible for an abortion” exposes a deplorable Nazi style attitude to people of conscience. To expect complicity of this nature is like in the words of Dr.Charles Oettle ordering a man who does not believe in the death penalty to blindfold the prisoner and load the rifles for the firing squad. The law then must be clear. An appropriately advertised venue where abortion services can be confined from diagnosis to counselling to the procedure and its sequelae can be the only logical option. 8. Abortion training for prospective medical graduates. Will the jobs at Government Hospitals be reserved for doctors who have no objections to performing abortions? Will disclosure of a conscience not to participate in abortions end up as grounds for job discrimination for nurses doctors and social workers? Would selection to specialise in Obstetrics and Gynaecology or Midwifery be dependent upon willingness to perform abortions as per the proposed act? If so, is this constitutional? These are practical issues with grave implications. The Government would do well to ensure that there are satisfactory answers before plunging the medical profession into a serious crisis by prematurely enacting this bill. Finally it is barely credible, that this body of elected individuals regarded as being people of integrity and role models for the citizens of this nation allow themselves to be dictated to against their consciences. Surely the coercion of elected members of parliament is in itself a gross violation of human rights and unconstitutional. Many MP’s in this house inwardly do not support the proposed bill but would appear that they are not allowed to express it. It is depressing that for political parties as supposedly democratic as the ANC and the DP, that the statement that their members on the Committee must vote against their better judgements. There was a time in South African History when brave men and women stood up against the tide of opinion and had the courage of their convictions to state their case. Some lost their lives for this. We would do well to remember that it takes a live fish to swim upstream. Have these elected officials become a grey amorphous herd of YES people? What has the country’s leadership come to when they can be coerced into voting against their own consciences? When the sinister agenda of a shadowy group of puppeteers hold sway behind a wall of raised hands, and the will of the majority is subjugated, the electorate begins to ask “ Just who is really running this country?”
Harvey R.G. Ward 5 Kamassi
Avenue, 4 April 1997. From: hward@ilink.nis.za /fax 021-5311488 To : masact@aztec.co.za /fax 021-5314126 The Editor, Dear Sir, Abortion Objectors: Rights and Responsibilities The Choice of Termination of Pregnancy Act passed recently in Parliament has brought with it some major logistic problems particularly as a result of doctors and nurses at many hospitals having moral objections to being involved . These objections range from not wanting to have anything to do with women requesting abortions to agreeing to all but the handling of the manual vacuum aspirator themselves. Many if not most objections are based on the reluctance to take or participate in the taking of an innocent baby’s life. Often however, zeal for the cause may result in avoidance of careful history taking, a full and dignified examination resulting in the sloppy handling of a patient who has made a choice albeit not one with which the attendant concurs. This is inexcusable and may be medicolegally negligent. I have occasioned to find that a woman requesting an abortion was not even pregnant, and another had an ectopic gestation. I do not object to confirming the presence of a normal pregnancy and declaring the woman medically fit although I do feel that had she wished to keep her pregnancy she would have been assessed at any antenatal booking clinic by a qualified midwife. Preliminary evaluation for these women should really therefore be performed at any antenatal clinic prior to referral. Clearly and simply explained options and alternatives to abortion should be made available in Gynae Outpatient departments (in the appropriate languages) for women before they are seen and examined by staff. She may then be able to inquire further from at least a better informed position. An objecting doctor has every right to refuse to write up or administer an abortifacient such as Misoprostol. If this service is to be provided, then appropriate arrangements should be made by the medical superintendent or regional director of Hospital services. I think it is indefensible for an objecting doctor or nurse to refuse to see a patient arriving at hospital as a threatened, inevitable or incomplete abortion even with the knowledge that an abortion had been procured. Certainly once the baby has been delivered, retained products constitute a grave risk to her future health and fertility. Refusal to attend to her would surely be medico legally culpable. If the objector feels that the method by which she aborted constituted grounds for refusal to treat then the corollary exists that he/she must refuse to see injured drunk drivers or attempted suicide patients. Compliance with seeing these patients on an emergency basis, however, ensures that what used to be regarded as an “emergency” now becomes “routine” and hence forces staff who object strongly, to participate in abortion service to keep the system running. This is stressful and highly unsatisfactory for the staff and should serve to motivate administrators to designate separate staff and facilities for fetocidal purposes. Some doctors and nurses attempt to stigmatize and even persecute colleagues who are prepared to do abortions and run the risk of allowing their difference of opinions to spill over into interpersonal relationships affecting cooperation on other work. This only polarizes the profession and generates more heat than light. The fact of the matter is that abortionists and objectors exist, are employed in the same institutions and will not resign their jobs. A clear statement of one's moral position does not mean a call to arms. The need to fully cooperate to provide the vast remainder of O&G responsibilities is critical and should not be threatened by this divisive issue. To expect one willing member to fulfill routine duties plus deal with the abortion load is grossly unfair and may be construed as merely avoiding work. With the passing of the new legislation, rights have been afforded without the means to accede to them for many women. Little if any attempt was made to assess the willingness of current medical staff to fulfill the requirements of the new Act. If the Government does not take the issue of conscientious objection seriously we face a very bleak and divided future. Any official attempt to discriminate against objectors will inevitably end up in the Constitutional Court at significant cost to all. If the current impasse is not broken with creative cooperation, the stalemate may threaten the very survival of our fragile medical network to the eventual detriment of all. Yours sincerely, Dr.Harvey Ward
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