International Safe Abortion Day: New clinical guidelines for South Africa to empower healthcare workers
The new national clinical guidelines for the implementation of the Choice on Termination of Pregnancy Act serve as an opportunity to strengthen services in providing much-needed clarity and guidance to health workers.
Marion Stevens is the founding and outgoing Director of the Sexual and Reproductive Justice Coalition (SRJC), PhD candidate | SARChI Chair in Gender Politics, Department of Political Science, Stellenbosch University. Gender Advisory Panel, World Health Organization. Dr Daphney Nozizwe Conco is an SRJC member, Senior Lecturer, School of Public Health, University of the Witwatersrand, and Principal Researcher, National incomplete Abortion Study SA, 2018 (in progress).
International Safe Abortion Day — celebrated every year on 28 September — marks a woman’s fundamental reproductive right to access safe, legal abortion. The Day of Action for Access to Safe and Legal Abortion has its origin in Latin America and the Caribbean, where women’s groups have been mobilising to demand that their governments decriminalise abortion, provide access to safe and affordable abortion services, and end stigma and discrimination towards women who choose to have an abortion.
The date — 28 September — was chosen in commemoration of the abolition of slavery in Brazil, which is now remembered as the day of the “free womb”, demanding safe and legal abortion for all women.
Every year opinion pieces are trotted out to mark this day and to serve as a reminder to readers. This happens as those opposed to vaccination in 2021, are co-opting the reproductive rights slogan “my body my choice”.
Liberal laws, limited access
South African policies articulate comprehensive sexual and reproductive services with an equitable and rights-based approach. Unsafe abortion, however, remains one of the major causes of maternal morbidity and mortality. The Department of Health estimated that unsafe abortions directly resulted in 23% of maternal deaths from septic miscarriages in public health facilities between 2008 and 2010. Additionally, the 2014-2016 Saving Mothers Report indicated unsafe abortion as an avoidable factor in 25% of maternal deaths due to miscarriage. Maternal mortality due to abortion-related complications in South Africa is likely underreported due to an overlap in how causes of maternal death are classified. For example, HIV accounts for 32% of maternal deaths and women living with HIV who die from septic abortions are likely to be recorded as HIV deaths, rather than termination of pregnancy-related deaths.
Even though most public healthcare facilities in South Africa could provide the service, currently it is estimated that only 7% of health facilities provide abortion services while some 50% of abortions take place outside the formal health setting.
The estimated number of women admitted with incomplete abortions was 44,686 in 1994 and 49,653 in 2000. This indicated a substantial strain on South African public hospitals. Currently, researchers at the University of the Witwatersrand are repeating this study to quantify the burden of admissions from incomplete abortions. This work has been affected by the Covid-19 pandemic and is under-resourced with limited funding as donors tend to fund international researchers and not locally-driven projects. Yet, we have learnt recently of endemic sexual violence experienced by teenagers with poor access to reproductive health services who endure unsupported pregnancies, which demonstrates the lack of intergovernmental department programming and investment for sexual and reproductive health.
There has however been some progress with the release of the National Clinical Guideline for the Implementation of the Choice on Termination of Pregnancy Act finalised in 2019 and currently being programmed with the training of health workers. These comprehensive guidelines address the option of medical abortion with pills. They also address two additional areas that have needed urgent attention to address the lack of access to abortion services — obstructing access and counselling.
One challenge to implementation has been the obstruction of access to services for those seeking abortion care. The guidelines provide a practical remedy for this and those who are refused access can report those who obstruct their right to access. It is important to note that these mechanisms are now more patient-centred.
According to the guidelines:
“Obstruction to access refers to any person or act which prevents an individual from accessing any part of a quality and lawful termination of pregnancy service, in a timely manner. This includes any person in or around a health facility, clinical or non-clinical, ranging from facility support personnel to illegal providers.”
In terms of the guidelines when a direct provider refuses care, the following standard protocol should be exercised:
- Section 10 of the Choice on Termination of Pregnancy Act notes that it is a crime for anyone to prevent a legal abortion or obstruct access to an abortion facility. The penalty is a fine or imprisonment for up to ten years.
- A register of termination of pregnancy services refused should be kept in each facility, noting the clinical details of the individual, the referral process, and the name of the clinician who refused services.
- A health care professional’s refusal to care cannot violate the right of other health care professionals who are willing to provide termination of pregnancy services. Healthcare professionals who are not willing to provide termination of pregnancy services must inform their facility manager in writing when applying for a position in the facility. Facility managers must confirm whether a staff member is fit to provide termination of pregnancy services when appointing staff. Each staff member who exercises a refusal to treat must be handled individually. Termination of pregnancy service provision should never be handled in a group, or as a group action. Refusal to treat only applies to individual trained healthcare professionals and not to groups, institutions, support personnel, or complementary services.
- In non-emergency cases, healthcare professionals who refuse to provide a termination of pregnancy service must still explain their refusal to the individual in a manner that is non-judgemental and does not stigmatise, they must explain to the individual their right to request a safe termination of pregnancy, refer the individual to a facility/provider who will conduct the termination of pregnancy, and update the facility register to note the refusal to treat.
Ancillary staff (e.g. reception, ward clerks, janitorial, catering, etc) and other healthcare professionals involved in the general care of a patient (e.g. pharmacist) may not refuse to provide general or standard care to an individual under any circumstances.
In South Africa, those who refuse to provide terminations of pregnancy do so in terms of section 15 (1) of the Constitution, which guarantees the right to freedom of conscience, religion, thought, belief, and opinion. But the term “conscientious objector” has recently been co-opted by anti-choice movements to refer to health care providers who refuse to provide abortions. Our legal provisions are extensive in providing an enabling environment for the right to reproductive health, bodily autonomy and gender equality.
The counselling guidelines provide some guidance on how to provide this care.
Counselling should be non-directive and non-mandatory and conducted in a manner that allows the individual to make autonomous and informed decisions. [It] should be confidential at all times and individuals should be informed of their right to confidentiality.
The counselling guidelines are informed by research conducted by South African psychologists who have provided a step-by-step guide to upskill counsellors.
These guidelines on counselling are critical amid reports of illegal abortion counsellors operating in the country under the guise of US-styled pregnancy crisis centres. Findings of an investigation by Open Democracy published in February last year showed there is a grouping with US funding and links with some established networks already in the country.
In terms of the guidelines these are the topics to avoid when talking to abortion seeking individuals:
- Never require an individual to disclose how they conceived.
- Do not shame individuals for lack of contraceptive use or any other behaviour that could be interpreted as leading to the pregnancy.
- Do not require an individual to divulge their reasons for wanting a termination of pregnancy or judge the individual for the pregnancy or their reason for wanting a termination of pregnancy.
- Refrain from using the word ‘baby’ or unborn child to refer to the embryo/foetus.
- Refrain from using graphic descriptions of foetal development, showing pictures of foetuses, or requiring the individual to listen to the foetal heartbeat.
- Do not communicate unproven, disputed, or false claims about negative physical and mental consequences of termination of pregnancy.
- Do not use religious references.
These new guidelines are an opportunity to strengthen services in providing much-needed clarity and guidance to health workers. They also serve clients should their care be obstructed and serve to inform about the kinds of counselling offered relating to abortion. The burden of ill health from lack of access to reproductive justice remains a devastating challenge for us and needs urgent redress. DM/MC
This article was first published by Spotlight – health journalism in the public interest.