3.

Results
Of the 308 doctors who were sent questionnaires, 169 (54.9%) responses were received. Analysis of the categories of personnel revealed almost 60% response from specialists, registrars and MO’s who occupy the tertiary and secondary DI’s almost exclusively (Table 1). 11 respondents declined to provide demographic details. Only 40% of GP’s sent replies.

Doctors were asked if they had occupied their current post at the time of the introduction of the law on 1^st February 1997 whether or not they would expect to be in the same post on 1^st January 1998 (Table 2). Of note is that 25% of medical officers would expect to change jobs but most other ranks would remain in their positions at least for the foreseeable future into 1998. Conclusions based on the opinions of the current staff complement are probably likely to be valid for 1998.

The profile of respondents according to rank and institution is recorded in Table 3. The tertiary hospitals employ the majority of specialists and registrars, the secondary hospitals are staffed mainly with MO’s with specialist cover, while the primary facilities are mostly MO and GP run.

Training to perform TOPs is a prerequisite for midwives according to the TOP Act ¹. However a significant number of doctors reported having had no training, formal or informal, in the procedures for pregnancy termination, manual vacuum aspiration or the administration of a paracervical anaesthetic block. (Table 4) . No such mandatory prerequisite for training is required by the law for doctors presumably because the procedures are expected to be within the scope of every registered practitioner. From respondents, it is clear that this is not the case for many doctors whom the State expects to provide abortion services in the Western Cape.

Among those employed largely at primary and secondary DI’s, 21.7% of medical officers and 27.1% of GP’s felt that they would be unable to deal, at their particular facility, with complications arising from abortions. While the nature of these complications were not specified and this may have been interpreted in various ways and with variable degrees of
[Contents]

4.

severity, it does nevertheless, reflect an expression of the confidence, or the lack of it, to manage these cases satisfactorily.

Asked if they would be willing to attend training seminars or workshops for TOP and related procedures, only one quarter of MO’s and GP’s were agreeable. 22% of specialists and registrars were willing to attend courses but a large number (>80% of specialists and >70% of registrars) indicated that they had already had some training, whether formal or informal.

The TOP Act advises non-mandatory, non-directive counselling for women both pre and post abortion ¹ . Although the term "counselling" was not defined in the questionnaire, a large number of doctors of all ranks admitted a deficiency of abortion counselling training ranging from over one third of specialists to more than 93% of general practitioners (Table 7).

The Department of Health has devised Values Clarification workshops designed to assist attendants with evaluating the practicalities of their own belief systems, their values and attitudes towards TOPs. Few respondents had ever attended such workshops (Table 8).

Thirty one hospitals in the Western Cape were designated as suitable for TOP service by the Minister of Health and Table 9 shows the actual provision of service among those institutions. Where the service was absent, the question was put to doctors as to where referrals would be sent, if at all (Table 10). The private sector (including private hospitals and clinics) and the free standing Marie Stopes clinic, a non-governmental organisation, are institutions requiring a fee for the procedure. These would therefore be the destination of choice for the affluent clients or for those who wish to avoid public exposure at a large hospital. The bulk of referrals are to the State hospitals, mostly to the two tertiary facilities; Groote Schuur and Tygerberg hospitals.

The percentage of respondents who indicated that they would not refer patients to another doctor or midwife comprised only one eighth at the tertiary DI’s (most women will be seen by a willing practitioner at these places), one sixth at the secondary and one quarter at the primary centres. This would create considerable logistic difficulties for any abortion applicant in a rural area

A small but considerable percentage refuse to even see abortion applicants at all. (Table 11).

Considering the diversion of most abortion applicants to the secondary and tertiary institutions, the question was put to doctors whether separate facilities and staff would be preferable for TOP services (Table 12). The overwhelming majority of doctors in the tertiary facilities were in favour while well over half of all other respondents would have preferred an off site TOP service.

The personal preparedness of doctors to become involved in the management of TOP applicants in accordance with the TOP Act was ascertained using a stepwise progression of questions beginning with pre-abortion counselling, to interview
[Contents]

5.

and examination, the procedure and, finally, post-abortion counselling. The "procedure" section was divided into: the prescription of abortifacients, the use of the manual vacuum aspirator or the performance of a dilatation of the cervix and curettage of the uterus. Respondents reflected widespread heterogeneity in the pattern of their answers (Table 13). Analysis of these responses revealed full cooperation with the law in 32.1%, a selective compliance to perform the procedures in 26.3%, compliance limited to non-procedural management in 26.6% and lastly, 24% indicated they would have nothing to do with applicants at all (contrasting somewhat with results from Table 11). Considering that data was missing in this section from only four respondents, it probably represents an accurate reflection of the level involvement of Western Cape state doctors in this process currently.

All TOP’s beyond twelve weeks gestation must be performed at a DI and by a doctor according to the TOP Act ¹. Doctors were therefore asked to what extent they were prepared to comply with the law for TOP’s greater than twelve but less than twenty weeks gestation. The Act specifies that TOP’s can be done only for certain conditions. However, different interpretations of these conditions do occur so the questionnaire offered a further detailed breakdown of categories of maternal and fetal factors (Table 15). The willingness of doctors to comply with the law for the various sub-categories is illustrated. The reason for most abortion applications is probably socio-economic and thus these women would constitute the bulk of termination clients. Only 31.5% of respondents would be prepared to terminate these pregnancies, 22.5% expressed a willingness selectively while 46% said they would not. This obviously creates conflict between personnel at the larger institutions where most of the women are referred from other facilities.

Despite the arrangement of TOP services at DI’s where willing personnel commence the procedure and arrange to be available the following day to complete it, the situation commonly arises that a women will begin to abort while another doctor is on duty perhaps after hours. This is not unusual given that women are provided with misoprostol tablets at the outpatient clinics and told to take them at a certain time after which they will start to bleed and then abort on the day that the prescribing doctor is on duty. The survey contained a section of questions to determine to what extent the doctor was prepared to continue with an abortion started by someone else (Table 16). Forty five questionnaires were missing data. Where the pregnancy loss would be inevitable or even incomplete, a significant number of respondents indicated that they would be unwilling to manage these cases with what would be expected as standard gynaecological care.

Lastly, when doctors were asked whether or not they were ever consulted personally, or by questionnaire, regarding their willingness to comply with the TOP Act, only 24.5% reported that they had ; and only 30.1% were ever informed personally of their rights should they wish to refuse to comply (Table 17).
[Contents] [...6]