There has been a lot of discussion about the recent vote in parliament where parliamentarians were given permission by the speaker to vote according to their conscience. It is a concern to those of us working in marginalised areas where public opinion is flimsy and populist and not based on negotiated principle. Because of a loophole in the Choice on Termination of Pregnancy Act that allows health providers to recuse themselves from providing services on the basis of conscientious objection we have medical graduates who are unable to do a cervical examinations, insert an intrauterine contraceptive devise and refuse to do any abortion care. If a woman comes into emergency with a septic or incomplete abortion, there is limited capacity within the health care system to be able to provide care. And the National Department of Health has not invested much thought into how to remedy this.
One of the clear commitments that the ANC has made has been its firm commitment to reproductive health and in particular the passing of the Choice on Termination of Pregnancy Act (CTOP), which is 20 years old this year.
Some twenty years ago the ANC voted as a united block. This was a caucused and informed party political position. The CTOP sought to replace the previous apartheid Abortion and Sterilization Act which essentially left white women accessing abortions and black women filling up gynaecology wards and mortuaries after unsafe abortions. And yes there were some ANC parliamentarians who did not present themselves to vote, but many will remember the picture of Sister Bernard Ncube punching the air in victory in newspapers. Sr Bernard, a Roman Catholic nun and ANC Member of Parliament, celebrated this transformative legislation. It was well noted and understood that not all Christians and clearly not all Roman Catholics oppose abortions. This followed a lengthy process of consultation with over 200 submissions to parliament from various groups, most of them supporting the proposed legislation.
There has been rising concern about President Donald Trump and the US Agency for International Development (USAID) who have a legacy of being hostile to women’s health, especially abortion and contraception. For South Africa the real crunch came in 2000 when President George Bush re-imposed the Gag rule which limited organisations which received USAID funds from working to promote abortion. This meant mainstream treatment groups and our Department of Health stopped having any training, management and investment of abortion services. A curious feature in South Africa is the 3 MPs of the African Christian Democratic party repeatedly being rebuffed in the courts and in parliament for attempting to reduce the rights within the CTOP, clearly being guided by their sponsors from the US. Now in 2017, one of the three has introduced a private members bill aiming to insert barriers for women to be able to access care. This has not been costed and is not consistent with the plans of the Department of Health in terms of budgets and priorities.
A consequence of American politics is a loophole that has allowed the practice of conscientious objection of health providers who recuse themselves from providing services to women. We have medical graduates who are unable to do a cervical examinations, insert an intrauterine contraceptive devise and refuse to do any abortion care. If a woman comes into emergency with a septic or incomplete abortion, there is limited capacity within the health care system to be able to provide care. The National Department of Health have not invested much thought into how to remedy this and are not engaging in human resources management processes to ensure that sexual and reproductive health posts are filled with providers who are skilled to do the work needed.
Conscientious objection as a concept is derived from military experience where a person objects to serving in an army to fight a war. The individual usually has to apply to be recused and faces a legal process at great personal cost. There is usually little cost to society and the person is directed to alternative harder or more menial work. In relation to abortion in South Africa it is being argued that this practice by health providers is not acting with their consciences as the decision is not regulated and can change over time with no personal sacrifice. The reality is this decision is viewed as quite selfish to the health system which suffers, and women bear the consequences of not having access to providers who assist them. As a result of this Conscientious Objection, almost 50% of abortions are performed in South Africa by informal illegal providers and women endure unsafe and unregulated services.
Early this month over 50 experts from 20 different countries met in Montevideo, Uruguay, to discuss the global experience of conscientious objection in relation to abortion and to explore remedial actions. Lessons were learnt from countries who had tried to regulate conscientious objection and human rights groups planning litigation to address implementation. Scholars suggest that a better phrase to use is that health workers who recuse themselves from providing abortions are being “dishonourably disobedient”, another military term for a conscript who has neglected their duty. Of note is the fact that abortion services are the only service that health providers are permitted to object to. Health workers provide care to drunk folks who cause motor vehicle accidents, addicts and abusive men without blinking an eyelid, even though they might not approve of their patients.
In 2017 black women still die from septic abortions. Women who learn they are pregnant and HIV positive on the same day are directed towards continuing their pregnancy. There is no programming for discussion between the health provider and the woman to enable different choices they may want to make. It is not surprising that so many women choose to use illegal providers at a late stage of pregnancy and many ‘concealments’ of births are reported in the media with foetuses being abandoned. Many women report paternity denial as a reason for wanting to opt for an abortion.
There is little support for, yet much judgment against, women who are following their own consciences and making sense of their options in a harsh South Africa which does little to provide sexual and reproductive justice. DM
Marion Stevens, Chairperson: Sexual and Reproductive Justice Coalition
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