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
Harvey R.G. Ward,
Bsc (Med). MBChB. DipMidCOG Registrar OBGYN
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.
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.
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)
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.
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.
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).
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 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.
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.
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.
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
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