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British Medical Bulletin 67:115-126 (2003)
© 2003 Oxford University Press
Abortion: developments and impact in South Africa
Department of Health, Pretoria, Republic of South Africa
Correspondence to: Dr RE Mhlanga, Cluster Manager, Maternal, Child and Women’s Health and Nutrition, Department of Health, Pretoria, Republic of South Africa. E-mail: mhlane{at}health.gov.za
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Abstract |
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The article seeks to clarify the context of the Choice on Termination of Pregnancy Act, 1996 (Act No.92 of 1996), the factors that led to its adoption and implementation including the role of research in support of policy development, the expanded utilization of professional nurses, and the respect and promotion of women’s right to life and well-being. The challenges that cropped up on the road to implementation and sustenance are also spelt out. It is important to evaluate the programme because this will assist South Africa to improve on the performance of service delivery. It will also assist other countries, both poor and rich, to progressively realize the promotion of human rights. Lastly, the article also seeks to identify areas that will lead to the improvement of women’s lives, and ultimately societal development and health.
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Introduction |
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South Africa reformed the abortion law in order to improve the health of women and prevent deaths among women. It is arguably one of the most significant steps in respecting the rights of women to choice and to bodily integrity. The Act—the Choice on Termination of Pregnancy Act, 1996—represents a departure from the past where the woman was always regarded as a minor irrespective of her age or marital status. It also represents a departure from the philosophy that the doctor would always know what is best, and make a decision based on his or her judgment. Access to safe pregnancy termination is easier, and maternal deaths from illegal abortions, though still occurring are reduced. The challenges to access include information availability, rurality, attitude of health workers and communities, and limited resources for counselling. The stigma attached to termination of pregnancy is something that the health system and health care community has to deal with.
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Background |
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South Africa has a high maternal mortality rate, especially among the African population. Septic abortion is a major contributor to maternal death incidence rates. Various studies had shown the incidence, extent and terrible consequences of unsafe abortion. However, little could be done because of the prevailing legal environment at that time. Under the Hippocratic Oath, abortion upon request or demand is prohibited. During the time before the passing of the Abortion and Sterilization Act, 1975 (Act No.2 of 1975), the application of the prohibition of abortion was so severe that one eminent gynaecologist and obstetrician was struck off the medical register. Hardly 3 years later, the Sterilization and Abortion Act, 1975 was passed and enacted in record time. This practitioner has had to live with the stigma and the consequences of that ruling.
The history of women is intimately linked to the history of the oppressed, in that women were not allowed to make any decision with regard to their lives, including their reproductive lives. Because of the continued morbidity and mortality among women of all races, the National Party government of South Africa introduced a law in the 1970s, the Abortion and Sterilisation Act, 1975 (Act No.2 of 1975). That Act sought to make abortion accessible under certain circumstances. The conditions that had to be fulfilled were so stringent that only women in urban and well-resourced areas could make use of the provisions of the Act. Many women who would benefit from the Act stayed in rural areas where only one or two doctors were present in a hospital, and therefore abortion could not be permitted, as the law required that at least three doctors agree that the woman needed a legal abortion! Some women from richer families or who could afford went overseas to procure termination of pregnancy. The Act therefore was part of the response to the need to protect the lives of the privileged (mostly white population), while neglecting the welfare of the many women who were in the rural areas, and who did not know of the facilities that could be available for legal abortion. Even the presence of such knowledge would hardly help as provincial hospitals were governed by the apartheid laws that forbade Blacks from utilizing White hospitals. This led to women seeking help in the unhealthy environments of backstreet rooms. The majority of these women died or suffered severe morbidity.
Women are responsible for caring for the family, yet they are marginalized when it comes to employment. They are oppressed because of their lack of access to financial resources. This then makes them vulnerable to be abused, for the sake of having a sure source of income. Men often take advantage of this compromised position. Women also depend on men to provide finances for them to access health care, with the result that women tend to present late for medical attention. In developing countries, poverty has a woman’s face.
South Africa is a strongly Calvinistic country, with other religions such as Roman Catholicism and Islam having a substantial affiliation. The apartheid Government influenced the church practices, and it was influenced by the church in its policies. The church also provided theological justification for the policies of South Africa. There is now a growing charismatic religious movement within the country, with varying levels of conservative persuasions with regard to reproductive and family health.
With the political liberation of South Africa in 1994, it was imperative that laws should start responding to the needs of the majority, and women were among those who needed their human rights respected, protected and promoted. South Africa started responding to the reproductive health needs of women by tackling one of the most contentious issues—abortion. South Africa was responding to the recommendations of the International Conference on Population and Development (ICPD) and the United Nations Convention on the Elimination of All Forms of Discrimination against Women (CEDAW).
The religious sector was engaged, though not comprehensively, but since the Act has been passed, there are continuing consultations and workshops to involve all sectors, especially men, in the promotion of reproductive health and contraception. The traditional leaders are also engaged in discussions so that they support this initiative. Community mobilization using acceptable messengers is very important.
After much debate and support from research institutions and academic institutions showing the burden of ill-health and death from septic abortion, and the need for legislative reform, the South African government passed the Choice on Termination of Pregnancy Act, 1996 (Act No.92 of 1996). Health workers provided inputs on the likely positive impact of easier access to safe termination of pregnancy services. The Act has a preamble, stressing that it would and should not be used as a method of contraception. Its passage was concomitant to strengthening contraception services and providing alternatives to women who would not be desirous or able to bring up children from unwanted pregnancies.
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Contents of the Act |
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Among the prerequisites to termination of pregnancy is the requirement that information must be provided with regard to alternatives that are available to the woman with regard to the unwanted pregnancy. The alternatives include foster parenting, adoption and maintenance.
The Act also allows registered midwives to undergo training in termination of pregnancy, and to provide the service for women who are up to 12 weeks pregnant (by dates).
A year later, the Ministry of Health established the National Committee for the Confidential Enquiry into Maternal Deaths (NCCEMD), and made maternal deaths notifiable. The NCCEMD investigates all maternal deaths notified, and makes recommendations to the Minister every 3 years. The committee makes special recommendations with regard to the termination of pregnancy (TOP) services in the country. This then places the Choice on Termination of Pregnancy Act, 1996 squarely in the strategy for reducing maternal mortality and morbidity.
The Act broadened conditions under which a pregnancy can be terminated. It divides the gestational period into three parts for the sake of termination of pregnancy.
- Up to and including 12 weeks gestation by dates.
- Above 12 weeks up to and including 20 weeks gestation by dates.
- Above 20 weeks gestation by dates.
The Act allows doctors and midwives who are skilled to terminate a pregnancy up to and including 12 weeks gestation. Only doctors are allowed to terminate pregnancies above 12 weeks under certain conditions. The Act has thus reduced the upper limit from the 28 weeks that is traditionally accepted as the cut-off point for viability. The Act also governs the termination of pregnancy up to and including viability, thus including induction of labour and caesarean section.
A woman of any age may request termination of her pregnancy without having to advance reasons for such, on condition the pregnancy is not more than 12 weeks gestation. After 12 weeks gestation, termination of pregnancy can only be carried out under certain conditions. These are: pregnancy having been the result of rape, severe fetal abnormality, severe maternal physical or mental disease, or if continued pregnancy would result in severe social or economic conditions. A pregnancy over 12 weeks but not more than 20 weeks may only be terminated upon the recommendation of a midwife or a medical practitioner, and upon the consent of the woman. It is of note here that the consent of the spouse, guardian or parent(s) is not required.
One of the features of the Act is the respect for women’s right to choose, irrespective of the age of the woman who is pregnant. The Act requires that health workers advise a child to consult with a parent, guardian or a family friend before the termination of a pregnancy. However, if the child chooses not to inform anyone, access to termination of pregnancy services shall not be denied her. The clause was deemed necessary given that there are children who may have been sexually abused by their guardians or parents. If the permission of the parents or guardian were necessary, it would pose a barrier to seeking help. It is this part which also poses difficulties in some circles.
The Act also makes provision for counselling before termination of pregnancy, though this is optional. Elements of information that must be made available to the woman include alternate options to the pregnancy termination. These include foster parenting, child support grant, adoption and maintenance from the biological father of the unborn child. The Act makes it possible for women who are considered minors to access termination of pregnancy without the consent of the parent(s) or guardian.
Regulations were developed and these set out criteria for facilities wishing to offer surgical termination of pregnancy. These regulations also established norms and standards for performing the procedure. The safety of the woman is the prime concern of the Act, and anyone terminating a pregnancy must be competent to do so, and must have easy and ready access to supportive equipment and resuscitation facilities. There must also be ready access to emergency transport should this become necessary.
In summary, therefore, the Act sets the limit of 20 weeks gestation as the boundary for viability, considering the first day of the last normal menstrual period. All pregnancies above 20 weeks gestation are considered in the same light as any viable pregnancy. The termination of such a pregnancy must be in accordance with normal midwifery and obstetric practice. Therefore, there are fewer grounds for termination of pregnancy as the pregnancy progresses. It is also based on the woman requesting termination of her pregnancy. It provides for the minimum information that must accompany the service. The Act allows midwives to carry out termination of pregnancy if they have the skills to do so. The Act also makes it an offence for anyone other than a trained health worker to provide pregnancy termination services. Facilities have to fulfil certain set criteria in order to qualify for termination of pregnancy.
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Clinical challenges |
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Though the Choice on Termination of Pregnancy Act was passed in 1996, it was only implemented in 1997, as the health system had to prepare and train health workers. A dilemma arose when women would present for termination of pregnancy before its enactment. The other challenge involved health workers who objected to participate in termination of pregnancy service provision. The Constitution of the Republic of South Africa protects the rights of workers not to participate on grounds of religion or personal conviction. This continues to be a challenge.
The challenges to implementing the Act lay in the provision of access to safe practices. The sudden freedom to choose would result in many women wanting to access the service. The approach was to obtain equipment [manual vacuum aspiration (MVA) in this case], drugs and people to perform the pregnancy termination. There was also the real danger that radical elements within the so-called Pro-Life movement would target health care providers. The challenge lay, therefore, in getting opposing factions to work together for the lives of women and children.
Women became frustrated by delays and deliberate obstruction to pregnancy termination services. Women would then access misoprostol to initiate the abortion, and present at health facilities with vaginal bleeding. Objecting (to the Act) hospital doctors and nurses would then refuse to attend to these women. The Health Professions Council of South Africa had to remind doctors that their duty was to attend to the woman who is bleeding.
The health services have difficulty in providing second trimester abortions. This is because many women at this gestational age require admission, and the Act allows only doctors to perform the procedure.
One of the provinces took the decision to centralize the TOP facilities within one major hospital until enough health workers were trained to decentralize the service. All the other hospitals would refer the women (or couples) to the hospital and bear the responsibility of providing transport for the women. This has worked very well, and access to TOP services has improved steadily over the years. The service has now largely been decentralized to district level in this province.
Training In South Africa, as in many other countries, gynaecological procedures are performed by trained doctors only. Doctors are trained to perform termination of pregnancy as part of their competencies during the internship year. However, it was necessary to equip nurses to perform the pregnancy termination, as there are very few doctors in the underserved areas, especially the rural areas. The demand for the service would also increase, thus overwhelming the available resources.
The methods for termination of pregnancy consisted of surgical evacuation of the pregnant uterus. The limitation of this became obvious early in the process, as the need for anaesthesia would make termination of pregnancy inaccessible where there are no skilled doctors to administer this. The MVA technique became the method of choice. However, few doctors in South Africa were familiar with the MVA of the products of conception. Dilatation of the cervix depended on either very expensive drugs such as prostaglandin tablets or gel.
Experiences elsewhere had shown the usefulness of misoprostol as a cervical ripening agent, as well as an abortifacient if used in conjunction with mefipristone. British experiences and practice informed the use of misoprostol. However, the company that made misoprostol would not consent to including pregnancy termination as an added indication for the use of the drug. The medical profession in South Africa has continued to use this drug for cervical ripening, as comparable drugs are unaffordable.
During the early phase of consultations before the Bill was put before parliament, there was consideration of the use of medical abortion. The requirements that France had put in indicated that there must be strict oversight for the completion of pregnancy termination. Such oversight could not be assured within the South African public health sector. Many women who would otherwise benefit from this would not be able to return for review to ensure that evacuation of the pregnant uterus has been complete. The alternative would be to admit the women until they have aborted. This is also not sustainable because of limited space within facilities. The issue of off-label use of misoprostol also became significant. For this reason, medical termination of pregnancy could not be entertained as a public health programme.
The training would therefore aim at providing TOP services at the lowest level of the health system as possible. Training involved the following:
- Values clarification workshops
- Identification of adequate numbers of midwives and doctors for the provision of TOP care
- Training in MVA for both doctors and nurses
- Development of management guidelines, including the use of prostaglandin analogues, especially misoprostol
- Contraception including emergency contraception, as pregnancy termination had to be accompanied by contraception counselling and advice
The Department and partners for the promotion and protection of human rights supported the health care workers through visits and refresher courses. Non-governmental organizations assisted in training for counselling and for provision of TOP services.
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Research |
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It became necessary to monitor and evaluate the quality of TOP services from the beginning. The opposition required evidence, and the benefits of the service had to outweigh the disadvantages. It was also necessary to look at newer and easier ways for conducting abortions so that the service could be provided at primary health care level. An advisory group of practitioners was constituted to carry out these functions. They looked at, among other things, the appropriate route for administration and the recommended dosage of misoprostol. The group also looks into ways of improving service delivery. It is important that quality of service is an important component of monitoring progress.
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Legal challenges |
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Soon after the implementation of the Act, a group of Christian professionals challenged the Act in a court of law. The group alleged that the Choice on Termination of Pregnancy Act, 1996 was unconstitutional based on right to life. The contention was that a fetus, irrespective of gestational age, has a claim to protection by the Constitution for its right to life, because it is a person. While the State recognizes the progressive development towards personhood, the fetus is not a person in law until its first breath at birth. Support for the pro-life lobby action came from, among others, the USA. The court, however, found in the State’s favour.
Another court case against the State was initiated recently by the same organization. As mentioned before, the Act has not found favour with all and sundry, particularly some of the religious organizations. The particular organization is objecting to the right of persons under the age of 18 years to having the right to make a decision on the future of their pregnancy without the consent of their parents. The point of view of the Department of Health is that the woman, once pregnant, should be in a state to make decisions about her own health and that of the fetus. The age of the woman is then of secondary importance. With the increase in reported sexual abuse, sometimes by a close relative, it means that some of the unwanted pregnancies are the result of rape by close relatives or friends of the family. It also means that the woman (adult or child) will be under extreme pressure not to report to the police or to terminate a pregnancy.
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Impact |
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TopAbstractIntroductionBackgroundContents of the ActClinical challengesResearchLegal challengesImpactConclusion |
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Since the implementation of the Act in 1997, there has been a dramatic increase in the number of pregnancy terminations in public health care institutions. The private sector has also responded to the need to provide the services.
The maternal mortality, though insensitive to immediate changes, if disaggregated yields important information. The process of maternal mortality therefore shows the changes that have occurred through the legal reform. There is a definite improvement in maternal deaths following septic abortion.
A recent study commissioned by the Department of Health showed that there is a decrease in the incidence of severely ill women admitted with incomplete abortion (Table 1). There was therefore less morbidity accompanying wilful and spontaneous abortion. The total number of women presenting with abortion, though, has not decreased significantly. This is explained in part by the fact that many women seek help at general practitioners’ rooms. Because these facilities are not designated in terms of the Act, doctors then advise the women to present to a health facility as soon as they start bleeding after taking misoprostol. In this way, women present early when the process of abortion is already established, before sepsis can set in.
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The Choice in Termination of Pregnancy has been accompanied by the use of misoprostol as a prostaglandin analogue. This has been a facilitating occurrence. However, this also has increased the illegal use of misoprostol by untrained people in order to induce abortions or labour. The incidence of the use of this and similar drugs is known, and the prevalence of unaborted fetuses that progress to term is not known.
Some health workers, especially some doctors, would refuse to attend to women bleeding if they suspected or knew that the pregnancy was terminated wilfully. The Health Professions Council of South Africa, the statutory body for medical practitioners, has issued a directive that any doctor refusing to treat a woman who is bleeding will be guilty of misconduct. The South African Nursing Council has also made a similar ruling.
The approach of the Choice on Termination of Pregnancy Act, 1996 is in line with the Human Rights Approach. Women’s rights are human rights. The previous Act (Abortion and Sterilization Act, 1975) afforded access to safe termination of pregnancy for a select section of the population, and it benefited mostly urban and more affluent and white persons requiring assistance with an unwanted pregnancy.
Because of the religiosity of the country, many people are opposed to the Choice on Termination of Pregnancy. The atmosphere under which health workers operate to implement this Act is therefore not supportive or enabling. The health workers are stigmatized and they need psychological support as well.
The Choice on Termination of Pregnancy Act, 1996 also opened the abortion issue for dialogue and debate. Radio, television, magazines and newspapers often carry space for debate on this topic. The heated and often malignant debates of the past are not witnessed that much these days, except under special circumstances in parliament.
Training of midwives Many pregnancy terminations have been carried out by midwives who have been trained in the procedure of manual vacuum evacuation. These health workers are now so good that they are even better placed to teach medical practitioners in the safe termination of pregnancy procedures. The Act has been cautious in allowing registered midwives to perform termination of pregnancy. The rationale for this was consideration of the skills that registered midwives already have with regard to pregnancy and the changes associated with such a physiological state. However, on review of the performance of registered midwives during the first 5 years of implementing the Act, the South African Society of Gynaecologists and Obstetricians recommended that consideration be given to training other categories of registered nurses to perform pregnancy termination up to 12 weeks gestation.
It is critical to have guidelines with regard to diagnosis and management of pregnancy. Because of limited resources, emphasis is placed on history and clinical examination for determining uterine size (gestational age). A uterine size of 16 weeks, even with a confirmed fetal size of 10 weeks (by ultrasound), would not be appropriate for a nurse to manage, because of the increased chances of complications. A pregnancy in a scarred uterus is also not amenable for management by a nurse. Use of prostaglandins in these conditions requires skills and vigilance.
Termination of pregnancy is associated with stigma in many communities. This also applies to the working environment, where some doctors and nurses discriminate against those providing termination of pregnancy services. This has led to some nurses leaving the service after only a few months of TOP service provision.
In an environment where there is violence against women, and many pregnancies are unwanted, access to termination of pregnancy has provided an alternative to women who are desperate and are not in a position to bring up a child. The Act has laid the framework for the promotion and protection of the rights of women, and to the promotion of reproductive choices. With proper skills transfer and support, it is also evident that health workers other than medical doctors can provide safe termination of pregnancy.
The ultimate aim of the Choice on Termination of Pregnancy Act, 1996 is to prevent morbidity from unwanted pregnancy, and to make TOP services available and accessible to all women, especially those in rural areas.
Parliament has established a process through which it monitors the implementation of the Choice on Termination of Pregnancy Act, 1996. It has already held two public hearings in order to hear the voices of women and stakeholders. The Act is currently being reviewed with the intention of making facilities more accessible, and to broaden the category of health workers to be trained to provide abortion services.
Research on medical and surgical termination of pregnancy is continuing.
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Conclusion |
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The success of this implementation also shows that it is possible for countries with limited resources to provide safer termination of pregnancy services, in a quest to reduce the number of maternal deaths from unwanted pregnancies and unsafe abortion practices. It is therefore important for the political leadership to make the environment supportive of women’s right to make decisions with regard to their reproductive future. Making abortion safer should be part of a greater commitment and initiative to improve women’s health.
Maternal mortality is still a major contributor to people’s development in developing countries. Unsafe abortion is a major contributor to maternal death and maternal ill-health. The attitude of patriarchal societies makes abortion a taboo, and therefore abortion never becomes a topic in the agenda of many countries, despite its negative impact on the health of women and children. It may indeed be time for the medical community to review the Hippocratic Oath, and remove those parts that, among others, discriminate against women.
Ensuring women’s rights is a political responsibility, and it is necessary for the political leadership to take the bold step, which is a necessary and human step, and commit the country to respecting, protecting and promoting women’s rights. South Africa took the decision based on sound scientific reason to respect these rights. The challenge is to further entrench these rights, and to ensure that the people most in need of relief are accorded access to services to prevent unwanted pregnancies and to safely terminate pregnancy when the need arises. The scientific community must provide the necessary leadership and support for excellence in providing necessary services for those in need, especially those in greatest need in terms of equity.
The words of the former Minister of Health, Dr Dlamini-Zuma, during the debates on termination of pregnancy in 1995, are appropriate as a conclusion. ‘No woman enjoys having a pregnancy terminated. Therefore as a society we should strive to prevent by caring. I shall be the happiest person, if, one day, even in the presence of the Choice on Termination of Pregnancy Act, no woman feels compelled to terminate her pregnancy!’
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