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Discussion
Published surveys to determine doctors’ attitudes towards more liberal abortion policies have been conducted in a number of countries, with most studies undertaken prior to proposed change in the legislation ^3,4,5. A search through the MEDLINE system using keywords: abortion, termination of pregnancy, doctors, doctor’s attitudes, objection, opinion survey; yielded very few published studies in the medical, legal and social science literature. In South Africa, the MASA study (1995) informally solicited opinion from 13 000 members from whom 1,476 responses were obtained (11.4%) ⁶. Firstly, the sample was not representative of those who would be expected to supply the service for the state and secondly, included those who were in a position to gain financially from such a relaxation of the law. This current study excluded doctors in private service in order to avoid potential for conflict of interest among respondents. However, those who are employed in a part time capacity are in a position to deny service to the indigent patient at the DI but might be willing to do it if she is able to afford the procedure as a private patient. Opinion surveys have included questions to determine the reasons why doctors adopt a moral position on the provision of abortion services ^3,4. This was purposefully omitted from this study but space was made available on the questionnaire for optional comment. Only limited demographic details were requested in order to maintain anonymity, which would hopefully ensure an adequate response. Even so, 11/169 respondents chose not to provide this information. The final 54.9% response rate ranked comparably with other studies where 55% of doctors in Barbados replied in a national survey ⁴, but much less than a large Australian postal survey (67.5%) for a single sending ³. This response possibly indicates a wide interest in the topic in the Western Cape. Non-responders may have either been disinterested or been concerned that they would be identified in some way and be vulnerable to pressure. Some were on leave at the time and some submitted the questionnaire too late for inclusion in the analysis. (four responses).

The State doctors working for the military hospitals and clinics were not included in this survey as a regrettable oversight (six doctors).

The relatively stable staff composition of the State gynaecological services provide a strong indication that the same doctors and their attitudes to the TOP Act, with the attendant consequences, would be likely to persist into 1998. Turnover among consultant specialists and registrars is slow with few leaving annually. The most mobile rank is that of the MO who comprises a significant proportion of doctors at secondary and primary institutions.

Training for TOP’s is either formalised at a structured workshop similar to the program designed by the Planned Parenthood of New York ⁷ or informal hands on type apprenticeship training. In this study, no training experience was reported by 20% of responding specialists, 30% of registrars, 69% of MO’s and 75% of GP’s. This, combined with an unwillingness to undergo specific training for TOP’s  reported by the majority of doctors, reflects the situation found
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 currently in the USA⁷.

Lack of training, or unwillingness to train, to do TOP’s coupled with the admission of lack of skills to use the manual vacuum aspirator or provide cervical anaesthesia implies that a medico-legally hazardous and dangerous service is being potentially offered at DI’s. The inability of over 20% of MO’s and GP’s to cope personally with abortion complications at their facility is a source of serious concern pointing to either incompetence or failure to provide continuing medical education or both. In reality, complications of induced abortions in DI’s should be rare, but obviously only in the hands of well trained personnel.

The majority of the facilities currently offering a TOP service are clustered around metropolitan areas (figure 4). Respondents were not asked to identify their area of work so we are unaware of which DIs offered either a full or a limited TOP service. The lack of access to abortion facilities acts as a barrier to the procedure because abortion service providers are scarce in rural areas where there are mostly primary DI’s ⁸.

Training programs for registrar and MO’s have been offered in the USA but they have encountered problems of slow recruitment, the disincentive for extra-mural education and scheduling difficulties due to the programs coinciding with hospital work ⁷. Facilities for training in the United States are scarce. Only 7% of hospitals offered a TOP service in 1996 compared with 50% of hospitals in 1973 soon after the Supreme Court case of Roe vs. Wade in Texas ⁹. Only 12% of medical schools nationally, provided a formal TOP training program with the option of residents with moral or religious objections not to attend these classes¹⁰. This has led to the establishment of first trimester abortion training programs at private clinics such as the three run by the Planned Parenthood Foundation of New York ⁷. (The Western Cape has only one free standing clinic in the Marie Stopes clinic in Cape Town city.) The program in New York includes modules on family planning procedure instruction, communication skills, response to patients’ reactions to the abortion experience, analgesia and anxiety treatment as well as details of abortion technique. The prevention of unplanned pregnancies is a vital component of such instruction. This latter topic should receive widespread acceptance among all doctors in South African state hospital service, as would sessions on the prevention and management of abortion related complications; immediate, delayed and long term.

A small study done from a teaching hospital in Cleveland with 20 registrars revealed that 57% had never performed a dilatation of the cervix and uterine curettage and 50% had no experience with either first or second trimester induced abortions ¹¹. Training to perform abortions is a prerequisite according to the TOP Act with severe penalties for defaulters ¹. Whether or not the two tertiary institutions and few secondary hospitals currently providing the service can offer formal training for TOPs is debatable given the expressed reluctance of survey respondents and their clearly stated preference
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 for separate staff and venues for abortion services (see later).

Recently, attempts have been made to increase the degree of integration of abortion training into residency programs in the United States and have resulted in the change of policy of the Accreditation Council for Graduate Medical Education ¹². This body has the power to effectively withdraw recognition of certain medical school and specialist training programs for registration with the American College of Obstetrics and Gynecology. However, those residents (registrars) with moral or religious objections to this type of training are not coerced to participate but are not exempt from practical instruction in managing abortion complications ¹³. In the major training hospitals in the Western Cape, the profile of emergency admissions offers ample opportunity to become acquainted with spontaneous abortions and the associated complications. With little modification, the necessary instruction regarding medically or surgically induced abortion can be provided for resident staff. This may be acceptable for registrars and MO’s in metropolitan hospitals but in the DI’s in the rural areas of the Western Cape (staffed by part-time GPs and midwives), logistical problems exist with this type of training. Willingness to be trained at all is of course a prerequisite.

Counselling has been strongly recommended in Section 4 of the TOP Act¹ but as it is non-mandatory, there is no obligation to provide it for those seeing abortion clients. The topics to be covered in such a counselling session, both pre and post abortion, have not been specified by the Act or gazetted so far. It is little wonder then that the vast majority of respondents report no counselling training, either formal or informal. Issues to be addressed in the pre abortion counselling session in a non-directive, non-judgmental environment, should cover among others:

• clarification of the facts of the pregnancy with confirmation of gestational age
• awareness of sexuality, linking pregnancy with petting and intercourse
• circumstances surrounding the conception, investigation of violent assault
• current key relationships, partner/s, family, close confidants social circumstances,
• financial stability, employment or scholastic details
• access to facilities to family planning and primary health care clinics
• post coital contraception
• sexually transmitted diseases
• future sexuality and fertility discussion, where relevant, regarding medical disorders explanation of the abortion procedure and anticipated events
• non abortive options for the unwanted pregnancy
• referral to other agents for psycho/socio/spiritual support

It is obvious that if counselling training is not offered or practiced in this province, then doctors will have little impact on
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