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Protection of Conscience Project

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Service, not Servitude
Background

Are State Doctors in the Western Cape willing to implement the Choice of Termination of Pregnancy Act of 1996?

An opinion survey conducted in the Western Cape in November 1997.

In fulfillment for the requirements of the FCOG (S.A.) part 2.

Reproduced with permission

H.R.G. Ward B.Sc.(Med), M.B.Ch.B.(Cape Town), Dip.Mid.C.O.G.(S.A.)
The survey is of particular interest in light of serious problems identified in 2002 in some South African Hospitals and a 2010 survey in Nigeria. Other relevant background information is available in the article No Place for Abortion in African Traditional Life - Some Reflections . [Administrator]

Contents


Introduction

Prior to 1997, the Abortion and Sterilisation Act of 1975 provided limited means whereby women in South Africa could legally procure an abortion. The number of legal Terminations of Pregnancy (TOP) approximated 500 countrywide annually but estimates in excess of 200 000 illegal abortions per year were given in part as justification for review of the law and to draw attention to the large numbers of women who would suffer, and had suffered already, the serious consequences of back street abortions if they were unable to procure one legally. With the change of government in 1994, a blueprint for a new legislation was designed to extensively liberalise the previous Act by transferring the final authority and decision to terminate the pregnancy to the woman herself (when the pregnancy was less than 12 weeks duration) and to a joint decision between herself and her doctor/midwife or social worker for pregnancies beyond 12 but less than 20 weeks. Abortions beyond this gestational age were to be permitted for exceptional reasons only.

This issue became a subject of intense national debate for the public, the body politic and the media. Public hearings were held over a number of days at the Houses of Parliament in Cape Town which gave an opportunity for interested parties to present submissions to the Portfolio Committee on Public Health. This was purported to provide valuable input from the public to the drafting of the Choice of Termination of Pregnancy Act (TOP Act) of 1996 which was formally gazetted on November 22, 1996.1 At least one submission drew the attention of the Committee to the problem of conscientious objection of doctors and midwives, the lack of facilities and the lack of training facilities for personnel.2 One of the features of this Draft Bill dealt with the requirement of an objecting practitioner to refer an abortion applicant to another willing colleague who would perform the TOP. Initially, this clause carried a penalty of a fine or imprisonment or both. It was subsequently removed from the final legislation after fierce opposition from represented practitioners.

Under the new Act, the Minister of Health would be granted powers to designate institutions in the country suitable for the performance of TOPs and the personnel at these institutions would be expected in the normal course of their duties to provide the full service as per the TOP Act. Only medical practitioners and trained midwives were allowed to carry out these procedures in strict accordance with the law, subject to severe penalties if they were underqualified or failed to record details of each TOP as specified in the Section 7.1

The media carried details of the new legislation and the rights to be afforded to women. From 1st February 1997, when the law was formally introduced, abortion applicants began to arrive at the designated hospitals to obtain legal TOPs. It soon became apparent that at the tertiary hospitals of the Western Cape, large numbers of State patients were referred from smaller designated facilities due to the unwillingness of personnel to do TOPs.

Eight months, following the passage of the Act, these referral patterns persisted and the number of applicants increased. In the light of this informally expressed dissatisfaction, it was decided to investigate formally the degree of compliance with the new act by doctors within our referral boundaries.

Objective

A study was designed and conducted in order to determine to what extent the doctors in the State employ at the institutions so designated by the Minister of Health, were prepared to comply with the TOP Act. From these results, appropriate recommendations could be made both internally, at a hospital level, and externally with the Department of Health as to how to accommodate doctors and the service best.

Setting

The geographical area chosen was the Western Cape primarily because this area was the referral base for Tygerberg and Groote Schuur tertiary hospitals. Fourteen secondary and fifteen primary facilities were identified. (fig 1)

Subjects

All doctors at the designated institutions (DI) in the Western Cape area who were in full or part-time State employ between 17 - 20 November 1997 and who were expected as part of their routine duties to interview, examine, counsel and perform abortions were included in this cross sectional survey. There were 308 doctors in all, comprising: specialists, registrars, medical officers (MO) and general practitioners (GP). The opinions of midwives, floor staff and anesthetic personnel were not assessed in this study.

Methods

The survey was conducted by sending a single questionnaire (figs. 2, 3) to each doctor via a contact person at the DI. This was accompanied by an explanatory letter and was enclosed with a self addressed stamped envelope for ease of return. All questionnaires were posted or hand delivered between the 17-20 November 1997. The contact person was reminded either by facsimile, or telephonically, both 2 and 3 weeks after the date of sending, to ensure that the envelopes were distributed and in turn, to remind doctors to fill them out and post them. It was decided not to use available lists of the names of doctors in the DIs and send the forms personally. This could imply that they had been identified and the risk of a poor survey return due to fear of identification was potentially serious.

The questionnaire was subjected to a pilot survey with ten doctors and three epidemiologists who screened the sections of the form for ambiguity or lack of clarity and their helpful suggestions were built into the final draft.

The questionnaire design was structured with answers able to be circled for ease of data capture, loading and interpretation.

The closing date for receiving replies was the 31st January 1998 but it was made clear to contact personnel that the only doctors who were eligible to submit a questionnaire were those who were in the relevant posts at the time of sending.

Only one mailing would be possible as it was decided, given the controversial nature of the subject matter and the concern over victimisation, that respondents were assured that they would remain anonymous.

The results were analysed statistically using frequency tables at the Centre for Epidemiological Research of South Africa, Medical Research Council.

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 1st February 1997 whether or not they would expect to be in the same post on 1st 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 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 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).

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 York7 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 currently in the USA.7

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 classes.10 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 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 preventing a recurrence in the woman herself, and perhaps more importantly, they will ignore the influence that a well-counselled woman may have on her peers and associates. Counselling for abortion-vulnerable women seeking help at a DI should be built in as a compulsory service from which no practitioner is exempt, whether an objector or not. It is the golden opportunity to impart vital and lifesaving information to women who are a high risk for sexual and consequent pathology and this education surely cannot be construed as objectionable as it is a fundamental function of all reproductive health staff. Mandatory attendance at Abortion Counselling Workshops, currently offered by the Department of Health, for all relevant personnel at DI's would go a long way towards implementing an effective public education program and need not force any doctor to perform a procedure contrary to his or her moral convictions.

Although 31 regional hospitals in the Western Cape area have been designated as suitable for offering a TOP service, only 9 offer a full service and 7, a partial or limited one. Of those providing a limited or no service at all, referrals to other institutions were indicated by respondents in Table 10. The bulk of referrals to the State hospitals accounts for the long waiting lists for termination that currently exist at the tertiary hospitals. For women who can afford private practice TOPs (some costing as much as R1500 or more) or the Marie Stopes clinic in Cape Town (costing R675)14 there is a wider choice of services, but for the indigent patient, 78% of doctors refer to another State institution. The crisis care pregnancy centres who offer pre and post abortal counselling, adoption advice, legal counsel and practical support are used by 16% of respondents.

Considering the lack of counselling skills of the doctors by their own admission, DI's should have a list of pregnancy care centres in their areas and offer referral of these women for all the support they can get given the desperate situation of an unwanted pregnancy. If the Department of Health approves of support and counselling such as that provided in accordance with the TOP Act at these centres, then consideration surely must be given to Government subsidies or funding for these initiatives.

Up to one quarter of respondents did not refer patients to anyone at all, possibly because they complied with the Act (in which case they did not need to fill in this section) or they genuinely did not refer women (Table 11). A smaller percentage, 11%, refused to see abortion applicants at all. The missing data in 55 returns indicates an even lower overall figure of doctors who will not refer women or see them.

Doctors were asked whether or not abortions should be performed at their institution. 40% of female and 57% of male respondents indicated that they did not want the service at their hospital and 11% of each group did not want the service at any hospital. Conversely, it could be interpreted that 89% of the doctors felt that the service should be supplied at some venue at least.

Separate venues and dedicated staff for TOP services were supported by 76% of tertiary hospital doctors and over half of those in secondary and primary DI's. One of the arguments given against establishing separate facilities is that they would become easy targets for violent protest or picketing.

Firstly, by confining the service to the large hospitals, some degree of protection for women and abortionists alike is offered as neither can be distinguished from the many other patients and staff using the facility. Abortionists and their families are often subjected to harassment or faced with intimidation. In America and in Canada, cases of murder of at least two abortionists, and many arson attacks on abortion clinics have strongly discouraged would be participants. To what extent a similar threat is present in South Africa is unknown. Due to the widespread objection to the practice of abortion in the USA, 86% of all TOPs in 1988 were carried out in these free standing clinics.8 This trend is increasing as in 1976 only 46% of TOP's were performed in these clinics. In 1996 in the USA, only 7% of hospitals offered a TOP service and more and more residents are refusing to undergo training to do abortions.9 Off site training venues have been suggested but have been poorly attended.7

Secondly, at a hospital, there is the advantage of the availability of medical back up in case of an emergency arising from a termination procedure.

Although clearly preferable to the respondents of this survey, the siting, funding, staffing, equipping and management of such clinics would present a significant challenge to a cash strapped provincial Government who at the time of writing have earmarked several provincial hospitals for closure mainly for financial reasons.15

The legality of forcing an institution to provide a TOP service, rather than the personnel who staff it, has been challenged in the United States of America.16 A service can only be rendered by a person who is protected against being coerced into performing acts, which may be legal, but bring them into conflict with their own moral or religious convictions. To exclude institutional health workers from a conscience clause protection would be an indirect way of denying conscience and morality in individuals for whom the conscience clause in the South African Constitution is written. The only other solution is to employ staff at the current DIs who would be willing to perform TOP's and include this as a dedicated post or part of a job description. Considering the degree of reluctance expressed in this study, there is a real possibility that such a post may go unfilled. In the USA, incentives have been suggested for staff who are willing to provide the service in addition to the other duties, in the form of extra compensation such as a US$1500 trip to a offshore medical conference! Interestingly, this was agreed to among all residents on that program.11

In summary then, unless staff who are willing to provide a TOP service are employed in the DI's in the Western Cape, or current personnel are prepared to change their positions on the matter or until separate facilities are widely established, the situation will remain in status quo and the service provision could even shrink if trends in the United States provide any indication.

The extent to which doctors are prepared to apply the law is reflected in the Tables 13 and 14. The heterogeneous spread of degrees of willingness highlights the complexities of having to structure a service at a DI. Ranging from full compliance with the TOP Act (23.1%) to complete refusal (25%), doctors in the Western Cape are determining by conviction the quantity and the extent of the service at their institutions. One study in the USA reported that 10-15% of gynecologists were morally opposed to abortions in all circumstances.18 Thirty per cent of junior staff and registrars were prepared to do elective abortions in another.11 Published figures elsewhere are scarce but this Western Cape study showed that 45% of specialists and registrars are prepared to fully implement the law.

The selective compliance with the law with pregnancies over 12 weeks present significant logistical problems in the tertiary hospitals offering the service. Cases are seen and evaluated by one willing doctor along with other gynaecological referrals at the busy out-patient clinic . Both registrars and students see and interview general gynaecological patients but only the senior staff evaluate the TOP applicants. They have to provide the counselling, do the interview and perform the physical examination. Referrals for sonogram and social worker may result in delays. By the time the woman has been found to fulfill the criteria for a TOP, another doctor may have to be found to write up misoprostol, or book her in for a TOP late in the afternoon (55% of tertiary hospital respondents, mostly registrars). This causes resentment and irritation which polarises staff . This problem is probably widespread and has been reported elsewhere.11

Women with pregnancies over 12 weeks applying for a TOP on the grounds of adverse socio-economic circumstances probably account for the majority of applicants in the Western Cape area. 46% of respondents in this study indicated that they would not do terminations for this reason, 22% were unsure and 32% would comply. This means that these women are referred from person to person, each of whom will personally evaluate her circumstances and decide for themselves as to whether or not they would also perform the TOP. This is most unsatisfactory for the woman and frustrating, time consuming and wasteful for the doctor whose responsibility it is to find someone to attend to her. This is not an isolated incident but a continuous daily reality in the tertiary institutions.

The problem of refusal is not confined to applications for abortions for socio-economic reasons. 50% of respondents would not do TOP's for non-lethal congenital abnormalities whether or not the problem was remediable medically or surgically. In reality, most of these cases are diagnosed antenatally with sophisticated genetic, biochemical tests and detailed sonar examination with specialist oversight. The tertiary hospitals have clear protocols for the management of congenital abnormalities so the terminations for this reason would be unlikely to cause delay or stress to the referring doctor.

Most specialists and registrars would terminate pregnancies for lethal congenital abnormalities, rape, incest, risk of maternal death or severe illness (as per the Abortion and Sterilisation Act of 1975). A slightly lower percentage of respondents would offer the service on the grounds of a woman's psychiatric condition.

The extent to which doctors wish to become involved in the TOP process is illustrated in the cases where, while on call, they are called to administer either misoprostol tablets or prostaglandin gel to a woman who has been admitted for a termination. Similarly, women who ingest misoprostol at home under one doctor's instruction, begin to hemorrhage then present to the hospital as an early pregnancy complication. Doctors were asked in the survey whether or not they were prepared to continue a TOP started by someone else. Forty five responses were missing but the remainder of replies revealed degrees of dangerous practice. With a threatened abortion, by definition, continuation of the pregnancy is possible (as for the woman who wishes to keep her pregnancy). Fifty seven per cent of respondents at the tertiary DI's would continue with the procedure but only one third at the secondary DI's, and less than half at the primary DI's, would do likewise.

The Tygerberg Hospital protocol instructs the abortion applicant to continue to take her misoprostol once she has started cramping pain or vaginal hemorrhaging in order to complete the TOP rather than linger with a partial pregnancy disruption.18 This may result in ongoing hemorrhage and significant blood loss. She is advised not to "abort the abortion " because of the unknown effects of misoprostol on the developing fetus which might survive the attempted termination process. Over 43% of doctors would not continue a TOP at the threatened stage but would manage the woman conservatively. After confirming fetal viability, and being satisfied that the woman was not actively bleeding and was hemodynamically stable, she could be discharged with analgesia with a view to return to her antenatal or gynaecology clinic. This is of course often in direct conflict with what the woman wishes and can precipitate heated exchanges leaving both the woman and doctor on call frustrated and emotional. Given that the reason for the terminations is often socio-economic (a reason for which most doctors would not do TOP's), these women present problems of conscience for many doctors. This is particularly unsatisfactory if the practice at a particular DI becomes established and no mechanism is put in place by the department administration to deal with these patients while still respecting the rights of those who find continuing a TOP morally repugnant.

The woman presenting with an inevitable or incomplete abortion requires active management according to well defined, nationally accepted current protocols. The survey revealed that a considerable number of doctors would manage these women conservatively (admission, sedation and no other active management) which may have serious consequences for the woman's health. It does reflect though the broad level of dissatisfaction among State doctors at having to manage these cases.

The practice of sending women home with misoprostol and requesting them to return when they experience symptoms and signs of impending abortion has significant risk. Although this enables women to take the final decision to commence the TOP themselves, it does have the potential to expose her to serious bleeding at home and in many cases, a considerable delay in getting to medical help. Frequently women report that after aborting at home, they must then gather up the fetus (occasionally alive) with placental tissue into a container, often a plastic packet, then share public transport such as a taxi, train or bus to get to the hospital, while still bleeding vaginally. The provision of facilities nearer the communities served will obviously avert this traumatic and humiliating experience.

In order for a woman not to be subject to unnecessary delays on admission to a casualty or Gynaecological emergency facility, she can elect not to divulge the information that she has commenced a TOP on herself. This would naturally avoid conflict with her caregiver but if any mechanical means has been used it is vital to the admitting practitioner to be aware of this and avoid the development of sepsis with antibiotic cover. A clear policy should be worked out in advance in each department within the parameters of the staff's rights and obligations.

Despite the extensive media coverage of the abortion issue, the rights of the woman and the rights of the fetus, plus the invitation for public commentary on the draft Bill on the TOP Act to the Portfolio Committee for Health in October 1996, less than 25% of all 163 respondents answered that they were consulted regarding their willingness to comply with the new Act. 30.1% of 139 had been informed of their rights to refuse to comply if they so wished. The current level of dissatisfaction reported by respondents could have been averted if negotiation with the end point providers had been considered prior to the passing of the law.

Abortions involve doctors' (and that of all other personnel) core ethical concerns about pregnancy and about life, prompting them, as this study shows, to determine for themselves what abortions, if any, they will do and on what terms. Autonomy of belief is a fundamental tenet of the South African Constitution and serves to protect any citizen from being forced or coerced to perform some deed against the dictates of their conscience. This may be weighed against the responsibilities expected of those whom the State entrusts the privilege of providing medical care.19

In South Africa, while refusing to refer an abortion applicant is not transgressing the law according to the Act, it is required of the doctor or midwife attending the woman to make her aware of her rights according to the TOP Act.1 This obligation does not contain a penalty clause so it remains to be seen whether or not a practitioner would be charged by the court for failing to fulfill this requirement. A simple solution would be to ensure that at every DI , there is available to every women attending the general or gynaecological outpatient department, a clearly worded pamphlet in the region's official languages detailing where facilities for TOPs exist should the staff at her clinic be unwilling to refer her. Whether "failing to refer" or "refusal to refer" could be construed as "prevention of a lawful TOP" or "obstructing access to a facility" as detailed in Section 10.2 of the TOP Act has yet to be tested in South African courts.1

The level of resistance internationally among doctors to abortion and other ethical dilemmas has prompted medical ethicists to consider at length the concept of conscientious objection.11,19,21 It is distinct from civil disobedience (applicable in South Africa only if the Minister of Health used the Section 9 of the Act to enact an amendment detailing doctors in the State employ to refer women subject to criminal action) and evasive non-compliance. Conscientious objectors seek to bear witness to principles and seek exemption from participating in what they consider to be immoral or evil. In this study, doctors were not asked to give reasons as to why they were unwilling to implement the law though opportunity was given to express comments at the end of the questionnaire. It is not necessary for a doctor or midwife at present to justify their decision as to why they conscientiously object to the TOP Act or any other legislation. This is in contrast to the requirement of the previous government which demanded that conscientious objectors to the conscription law must present written submissions and if necessary be prepared to be questioned before a court. Penalties ranged from alternative service to imprisonment. Some authors have suggested that all personnel having objections to the law be expected to provide a justification consistent with their beliefs,19 although such a system in South Africa could be costly and difficult to implement.

An alternative would be to create specific posts for the purpose of TOP services with a clear job description or to advertise posts informing prospective applicants that their application would be preferred if they were prepared to do TOPs. This however may result in many posts remaining unfilled and the collapse of vital services because sufficient numbers of willing staff cannot be found. Separate facilities with separate staff appears to be the most logical and indeed if the study findings are to be regarded as meaningful, the most preferred solution to this problem.

In 1994, Dooley warned that prior to a country drafting abortion legislation, a prudent government will consider in advance how it will find enough health care professionals who will in good conscience assist in abortions.21 In too many countries a law permits abortion and requires health professionals to implement the law but little or no attention has been given the basic principle of respecting conscientious refusal. This issue was raised again in the South African parliamentary public hearings in October 1996.2 It appears to have gone unheeded and the current unsatisfactory situation continues to exist.

Comments

Comments by respondents were offered by almost one half of respondents (79/169) and could be grouped subjectively into:

anti abortion: totally 19
selective: pro- or anti- 28
pro choice: totally 15
personnel forced or threatened 4
suggest separate facility 2
Act passed without consultation 2
study biased 2
forced to attend a TOP course 1
not a form of contraception 1
refused a post for objecting 1
compared with Nazi/apartheid compliance 1
too old to work in theatre 1
wanted questionnaire in Afrikaans 1
return Afrikaner rights 1

Comments aimed against or for the process of TOP's, or the law itself, were expressed most frequently, and opinions reflecting a selective approach to the application of the law or a preference/reluctance but not a refusal to do all abortions, comprised most of the responses. A number of other comments revealed some important insights into local hospital politics and philosophy. Four respondents reiterated their call for separate facilities, and two noted the lack of consultation with doctors prior to the TOP Act specifically. Two specialists felt that aspects of the study revealed bias but did not specify how the bias was defined. Two other respondents made reference to cultural issues not directly related to abortion per se.

Five respondents reported that they had felt coerced at their DI. Four of these comments are presented:

" I am very frustrated that tertiary institutions (registrars) are being "blackmailed" to do TOPs. Consultants have a choice, registrars don't. At the end of the day, the procedure is done by a registrar against his (sic) will, as quickly as possible and the patient doesn't leave the institution with new insight/information/follow up. Doctors and patients are frustrated and scarred victims of a poorly run/designed system."

" This is a sickening law enforced at my institution by enthusiasts at the head, hence any objection is actually held against you though its said in a subtle manner. I pity the juniors who object because they are threatened and told they wont do certain rotations which are essential to their specialist training. It's a mind set gone sick."

"The daily confrontation with issues around TOP's by staff who have strong moral objections to TOP's 'on demand', cause considerable stress and have a strong negative impact on work satisfaction. This type of work should be removed from the daily workload of people who are not happy to perform TOP's."

"There is widespread bias in the medical field towards drs. that agree to do TOPs. I was refused a Medical Officer post in a well known 2° hospital because I refused to do TOPs. Drs are being chosen for MO casualty posts depending on whether they will do TOPs or not, not on the skill or abilities as a practitioner. That is grossly unfair."

Clearly the clash of conscience and pragmatism is being felt at the ground level by these survey respondents. Perhaps most chilling is a comment on the blunting of conscience and resignation to provide a TOP service:

"I initially refused to take part in TOP's but have been drawn into doing them when other people are not available. Perhaps this is how the Nazi and Apartheid human rights violations also started."

Very strong feelings were reported regarding this Act and its implementation and this suggests that it is an issue that will not go away easily. The surveys result deserve some reflection and are followed by recommendations which should address at least some of the major matters arising.

Limitations

The study has obvious limitations in that the opinions of other personnel, such as midwives, nursing staff and anaesthetists, who are also involved, were not evaluated. Reasons were not specifically requested but were occasionally given for being unwilling to implement the Act. There are limitations to the depth of analysis in that it is not possible to determine where and how extensive the levels of resistance are by area or region.

The demographic details of the full staff complement could not be determined as it was realised, if this information had been elicited beforehand, respondents could have been identified by virtue of their profile match and guarantee of anonymity could not be preserved.

The complement of MOs will have changed by 1998 (25%) however, it is equally possible that with new personnel, the provision of TOP services could either be expanded or existing services withdrawn. Only regular surveys of current opinion will determine the extent and validity of an assessment of doctor's willingness to implement the TOP Act at any time.

Recommendations

Short term solutions to the issues raised by this study are proffered.

  • Each designated institution must clarify to what extent current and intended future staff wish to implement the TOP Act.
  • Each designated institution should advertise to women at the point of service whether TOP's are performed at that venue, and in the event of referral, specify the mechanism that is available to refer to the appropriate centre.
  • Each institution should ideally have a liaison staff worker to handle applicants' inquiries, to advise on options and pregnancy support and to provide preliminary counselling.
  • Each institution should compile a list of support services, such as pregnancy care centres, adoption agencies, counselling services and "safe homes", in their area and encourage them to advertise in the outpatient waiting rooms.
  • The staff responsible for gynaecological services and the local Health authority should combine to provide a strategy for the prevention of unwanted pregnancies. Family planning, post-coital contraception hotlines, safe houses in high risk communities, and school education programs stressing responsible sexuality and empowerment of women in the community setting to avoid sexual harassment and exploitation.

The longer term solutions arising from the study include the following:

  • It is the opinion of the majority of respondents that consideration must be given to the establishment of separate venues with dedicated staff to offer the abortion service.
  • Counselling training should be made mandatory for any doctor seeing abortion vulnerable women in the State service. Workshops held by the Department of Health can be arranged regularly to ensure all staff are able to attend.
  • Formal instruction in TOP's, and their complications, should be provided for registrars and MO's as soon as possible on entry into the department whether they agree to, or object to, performing TOP's or not. This will at least ensure that abortions and their complications are well known by all doctors and management of emergencies and complications will be appropriate.
  • Combined meetings with the hospital management, the Department of Health representatives, and the health care providers to determine how to reduce the numbers of unwanted pregnancies in those communities and how to structure the TOP service in that area.
  • Community resources, church and other interest groups should be included to become involved in not only the issue of abortion, but the attendant social pathology that so often accompanies it.
  • Constructive engagement of pro-life and pro-choice forces in the region so that resources can be pooled to tackle the problem of exploited and hurting women who resort to abortion often with little care or support, whether they decide to go through with the TOP or not.
  • Studies on the reasons why doctors are unwilling to do abortions would be helpful in understanding their expressed resistance. Further research into the attitudes of doctors and midwives towards the performance of abortion, and the psychological long term effects on both the mother and abortion provider will be important to undertake for the well being of both. Studies similar to this determining the willingness of nursing staff would be useful in the planning and execution of the dictates of the TOP Act.

Studies on the follow up of women who have had terminations will provide a valuable audit of the effectiveness of the counselling given. A survey should determine the persistence of factors in her lifestyle or situation which contributed to the unwanted pregnancy in the first place (such as lack of contraceptive use or alcohol abuse).

South Africa has a fragile network of medical services under financial siege and facing enormous obstacles in the face of an avalanche of diseases such as HIV, tuberculosis, and malaria. Abortion for many women is a desperate option in a desperate situation and because of its inherent moral problem - that of the sacrifice of fetal life in the interests of maternal health - threatens to polarize the medical profession in the employ of the State in the Western Cape who clearly have a wide spectrum of convictions. Conflict in this arena runs the risk of generating more heat than light and may ending up damaging the fabric of interpersonal relationships between colleagues as well as jeopardizing cooperation in other spheres of reproductive health service provision. The destructive engagement experienced in other countries should be avoided in South Africa as far as is possible. All personnel in this field can join forces to reduce the number of unwanted pregnancies - a laudable common goal. Our collective energies can be directed towards prevention while still maintaining a mutual respect for the strengths, capabilities and convictions of others in the field of Reproductive Health.

Acknowledgements

The thoughtful advice and suggestions of Professor H.J.Odendaal are acknowledged with grateful thanks. Data processing and statistical comment was provided by Dr.C.J.Lombard of the Centre for Epidemiological Research (South Africa). Comments and criticism of study design were appreciated from pilot study participants and Drs.C.Parry and J.Volmink, and Ms. D. Bradshaw of the Medical Research Council. Ms. Marie Adamo from the Cape Town Dept of Health kindly supplied the relevant Government documents and information on designated institutions.


References

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