Letter to The Secretariat,
Theme Committee IV
Constitutional Assembly,Cape Town

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

b. Confirmatory pregnancy test - midwife/nurse/pharmacist

c. Gestational age confirmed/sonar - midwife/doctor/radiographer

d. Pre procedural counselling - midwife/doctor/clinical psychologist/social worker

e. Pre anaesthetic examination - doctor/nurse?

f. Psychiatric assessment if needed and >14 weeks - psychiatrist

a. Sign an informed consent form: - doctor/midwife?

b. Premedication: - doctor

c. Pre operative anaesthetic assessment: - Anaesthetic GP

d. Surgeon: - doctor/sister

e. Anaesthetist: - anaesthetic GP

f. Theatre facilities - hospital/ clinic

g. Theatre staff: - scrub nurse/recovery nurse

h. Post operative analgesia: - doctor to prescribe

i. Histology: - pathologist/registrar

j. Post procedural counselling: doctor/nurse/psychologist/social worker

k. Audit and analysis: - midwife/doctor/statistician               

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,