Access denied

Ntsiki Mpulo, Spotlight

Activists blame government for limited access to abortion services in the public sector.

The streets of Hillbrow bustle with morning traffic. Taxis shoot in and out of the wide avenues as the Spotlight team passes through the palisade fencing and glass doors leading to the overcrowded entrance of the Hillbrow Community Health Centre. Patients sit in queues awaiting attention in the reception area and in the casualty ward. There is a din, as traffic noise competes with hundreds of conversations.

The uniformed security guard dispenses directions and acts as a traffic officer, redirecting people to different areas of the clinic in response to questions: where should I go for this ailment, what should I do with this piece of paper? She is a fount of knowledge – of necessity, as there is little signage other than the ‘Reception’ sign at casualty.

When we ask where the area for termination of pregnancy is, she informs us that the facility no longer offers this service. The sister who used to provide the service left some six months ago, and no-one else wishes to provide it.

This is the dominant narrative in many facilities across the country, according to Professor Eddie Mhlanga. Dr Mhlanga, a devout Christian and an obstetrician, is a strong proponent of choice in termination of pregnancy. He was director of the National Health Department’s Maternal, Child and Women’s Health unit from 1995 to 1999. During that time, he spearheaded the development of legislation to legalise abortion.

In his view: though the legislation is in place, in practice, women are being denied the choice to terminate unwanted pregnancies, because the prerogative of choice over women’s bodies is given to health workers. This is an untenable situation.

“Black women have little or no rights over their bodies in this country,” says Dr Mhlanga. “Their autonomy is restricted by patriarchy, in the guise of cultural practices.”

This is a view shared by outspoken sexual and reproductive health activist Dr Tlaleng Mofokeng, who does not pull any punches.

“Patriarchy and misogyny are systematic,” she says. “Power relations are stacked against women; so when they go into facilities, they feel like the healthcare professional is doing them a favour.”

According to a policy brief by Critical Studies in Sexualities and Reproduction, a research programme based at Rhodes University, just over six out of every 10 (63 per cent) young women in Buffalo City Municipality in the Eastern Cape are not aware of their right to obtain a free abortion in the public sector.

“You can’t fight for a right you don’t know you have,” says Dr Mofokeng. “It suits the department not to do a health education drive on abortion.” It seems the department is not interested in upholding the Termination of Pregnancy Act.

“It was reported some five years ago that only 40 per cent of facilities designated for providing this service were operational,” explains Dr Mofokeng. “This means there is a higher risk of women going to clinics in the second trimester, looking for surgical options – where they won’t be helped.”

Every healthcare facility should be able to offer a medical abortion up to 12 weeks, on a woman’s request. But this is not the case; a large number of facilities have insufficient or no trained personnel, and there is no protocol for referring the woman to another facility. In addition, there are often medicine stock-outs, or the drugs required are not listed on the essential drugs list.

According to Dr Mofokeng, the lack of access to abortion services is the result of a lack of care for women on all levels – from the government itself, represented by the Department of Health, to the Ministry, which does not have accurate statistics. They don’t know and can’t quantify the magnitude of the problem; they are disinterested, and disengaged from all the illegal posters advertising medical procedures.

“This is a primary healthcare issue, and it is the Department’s problem to solve,” says Dr Mofokeng.

Approach abortion with compassion

Spotlight attended a termination-of-pregnancy training workshop delivered by venerated sexual and reproductive health rights activist and medical practitioner Professor Eddie Mhlanga. During the workshop, Dr Mhlanga outlined the circumstances under which a woman of any age may obtain a legal abortion in the public sector. He emphasised that a woman does not require consent from anyone to undergo the procedure, but that those under the age of 18 should be counselled to inform their parents or legal guardian.

Circumstances and conditions under which pregnancy may be terminated

Gestation PeriodCircumstances and Conditions By WhomRequirements
Up to 12 weeks On the request of a pregnant woman of any ageRegistered Nurse
Registered Mid-wife with appropriate training
Informed consent of the pregnant woman
13 to 20 weeks Continued pregnancy poses a risk of injury to a woman’s physical or mental health
Would affect social or economic circumstances
Severe physical/mental abnormalities in the foetus
Pregnancy is a result of rape or incest
Doctor Informed consent of the pregnant woman
After 20 weeksIf the pregnancy would:
Endanger the woman’s life
Result in severe malformation of the foetus
Pose a risk of injury to the foetus
Doctor Informed consent of the pregnant woman;
consult 2 doctors, or a doctor and a midwife


Here are some of the questions we posed to Professor Eddie Mhlanga.

Who are the women seeking abortion?

“The majority of women who seek to terminate pregnancies, according to the health professionals Spotlight interviewed, are teenage girls. They report that sometimes girls as young as 14 years of age come to their facilities seeking abortions because this is their second child, and their families had forgiven them for the first ‘mistake’, but would not tolerate another; while others report having relationships with teachers or married men, and are not able to look after a child.

Sometimes it is a married woman who has ‘stepped out’ on her husband, who is perhaps out of the province. “I had a case where a woman came to me pregnant with her eighth child,” says Dr Mhlanga. “She had asked the doctor who delivered her seventh child to tie her tubes, but he failed to do so. She was a poor woman who survived on the grants provided by the state, and she simply could not afford another child. In this instance, the compassionate thing to do was to provide her an abortion.”

How many healthcare facilities offer termination of pregnancy services?

“In Mpumalanga, there are 23 facilities in the public sector that offer termination of pregnancy services. This is up from only five facilities three years ago. It is because we conduct training sessions for health professionals throughout the province, and even offer this training to other provinces. We trained doctors and nurses from Gauteng not too long ago.

In Gauteng there are 25 facilities, the majority of which offer the service only for women in their first trimester. Second-trimester terminations are only available at:

  • Chris Hani Baragwanath Academic Hospital
  • Sebokeng Hospital
  • Odi District Hospital
  • Tembisa Hospital

Services have been terminated at Dr George Mukhari Academic Hospital and Hillbrow CHC.”

How many women die as a result of unsafe abortions?

“The Minister of Health has said in a radio advert that a woman dies every eight minutes as a result of unsafe abortions; however, there are no statistics to corroborate this assertion. During my tenure at the National Health Department, we worked on the protocol for confidential inquiry into maternal deaths, which is published every three years. The last report, published in September 2015, looks at 2014 data; which revealed that in all maternal deaths, 57.3% were considered potentially preventable within the health system. However, there is no data specifically on maternal deaths caused by unsafe abortions.”

What do you think about conscientious objection?

“All healthcare professionals have taken an oath to deliver health care to all who live in this country, as stipulated in section 27 of the Constitution. Therefore, they do not have the right to object to offering the service, and the government should not enable this type of intolerance.

Compassion for the pregnant woman’s circumstances should be the primary motivation for any health worker. Currently, there is no provision in the Act for conscientious objection; and so, health workers are using the lack of clarity to deny women their right to health care.

Many health workers do not have a problem completing a botched abortion, irrespective of the cause; but they refuse to perform one at the request of a pregnant woman. This is grossly unjust.”

The ACDP has presented a private member’s bill to amend the Act. What do you think of the provisions they are suggesting?

“They recommend that a woman has an ultrasound. It is not only a coercive strategy to limit women’s ability to choose to terminate a pregnancy, but also impractical. Currently, there is no curriculum for training doctors to perform an ultrasound examination; it is simply not available in the public service. So this would be an additional burden on an already overburdened system.

In addition: in law, a foetus only becomes a life when it takes a breath; and thus, the argument that terminating an unwanted pregnancy is taking a life holds no credence in law.”

Dr Mhlanga is a lifelong advocate for the sexual and reproductive health rights of women, including the decriminalisation of sex work.

Read the full Spotlight: Youth Edition

Bill would roll back right to choose

 

Thabang Pooe, SECTION27

A new Bill threatens the very essence of a woman’s right to bodily integrity and reproductive decision-making, as well as the right to dignity.

Wednesday 31 January 2018 marked the 21st anniversary of the adoption of

Abortion Adverts, Cape Town, South Africa (Image: Egg Images, Alamy)

the Choice on Termination of Pregnancy Act (CTOPA). CTOPA states clearly that every woman, regardless of her age, has the right to a safe abortion. The rationale of the Act is to determine under which circumstances and conditions a woman may terminate a pregnancy.

CTOPA sets the context in its preamble:

“Recognising the values of human dignity, the achievement of equality, security of the person, non-racialism and non-sexism, and the advancement of human rights and freedoms which underlie a democratic South Africa;

Recognising that the Constitution protects the right of persons to make decisions concerning reproduction and to security in and control over their bodies;

Recognising that both women and men have the right to be informed of and to have access to safe, effective, affordable and acceptable methods of fertility regulation of their choice, and that women have the right of access to appropriate health care services to ensure safe pregnancy and childbirth;

Recognising that the State has the responsibility to provide reproductive health to all, and also to provide safe conditions under which the right of choice can be exercised without fear or harm.”

Clearly, the Act places a woman’s agency and autonomy centre stage.

Nevertheless, there are still serious challenges facing the implementation of CTOPA nationwide. According to HEARD’s, South Africa Fact Sheet on Unsafe Abortion, there is an estimated 50% of abortions in South Africa that occur outside of designated health facilities. Healthcare provider objections to providing abortion procedures result in fewer than half of government-designated facilities providing abortion services. The lack of real access to abortion services – due to lack of facilities and equipment required, and widespread ‘conscientious objection’ to abortion on the part of healthcare workers (including outside the legislated perimeters of such objection) – already violate women’s rights.

This points to the need for policy shifts that will enhance access to legal and safe abortion services for women in South Africa – unlike the amendments to CTOPA tabled in Parliament by Member of Parliament (MP) Cheryllyn Dudley in July last year. Dudley, MP for the African Christian Democratic Party, published a draft private member’s Bill, proposing certain amendments to CTOPA.

The stated objects of the draft Bill are to “delete certain circumstances in which a pregnancy may be terminated”; and to “ensure that a pregnant woman has access to ultrasound examinations and sufficient mandatory counselling to enable her to make a fully informed choice regarding the termination of her pregnancy”. This would include providing for mandatory counselling of women seeking abortions, including showing them images of foetuses in wombs.

The draft legislation is also intended to tighten conditions for allowing a woman to have an abortion in the second trimester, by requiring that a social worker must agree with a doctor’s determination that continued pregnancy would significantly affect the woman’s social or economic circumstances. Further, it would scrap provisions that permit a third-trimester abortion if there is a risk of injury to the foetus.

The Bill has been met with fierce opposition; mainly because in reality, the draft Bill aims to limit women’s ability to access safe abortions in health facilities around the country – thereby limiting, without justification, a woman’s constitutional right to equality; dignity; bodily and psychological integrity, which includes the right to make decisions concerning reproduction; privacy; and access to healthcare services, including reproductive health care.

Perhaps it is necessary to look at the proposed provisions more carefully.

 

The Bill eliminates two important circumstances in which women are currently able to terminate a pregnancy:

where the continued pregnancy would significantly affect the social or economic circumstances of the woman; and

where the continued pregnancy would pose a risk of injury to the foetus.

 

This is further exacerbated by the Bill requiring that the gestation period calculated is confirmed through an ultrasound examination, and introducing additional requirements for facilities that may provide abortion services – namely that the facilities must give access to ultrasound equipment and ultrasound examinations, and must give counselling.

These provisions are problematic on multiple fronts.

Firstly, our Constitution recognises that women have control over their bodies and reproductive capacities. This is located in a woman’s right to bodily integrity and reproductive decision-making, as well as the right to dignity. Forcing women to carry a foetus to term is an invasion of these rights.

Furthermore: properly understood, these rights ensure that the decision to terminate or not is made within the actual context of women’s lives; the removal of the ability of women to obtain an abortion – for social or economic reasons, or if the continued pregnancy would pose a risk of injury to the foetus – violates women’s rights to equality and bodily integrity.

Secondly, not all public facilities (as designated by CTOPA) will have ultrasound equipment or the expertise to undertake the tests that would be required by the draft Bill. In truth, ultrasound machines and healthcare workers able to operate them are frequently only found in major hospitals – and not at clinics, which is where women often seek (and are entitled to seek) abortion services. The unavailability of equipment or personnel would be an additional and unreasonable barrier to accessing abortion services. The additional restriction would also not improve the health outcomes of women accessing these services.

 

The Bill proposes mandatory counselling that includes showing images of the foetus in the womb.

In reality, the Bill seeks to introduce fear and shame into the counselling process by requiring that women be exposed to images of a foetus, including electronic pictures, diagrams and photographs. This is hidden under the guise of ‘informed consent’. The proposal to force this kind of counselling on a woman who seeks an abortion not only violates the woman’s dignity, but may serve as a barrier to access. This contradicts the rationale of the Act, which is to provide important reproductive health services to women in a way that respects their dignity.

Studies have already shown that currently, the way counselling is conducted amounts more to rhetorical scare-tactics, which construct abortion as firstly, a medical procedure associated with a wide range of extreme consequences; and secondly, as an act that contravenes the accepted purpose of ‘mothers’ (pregnant women) to protect their ‘babies’ (foetuses). The Bill would only serve to add to this, in violation of our legislative framework.

In sum, the proposals in the draft private member’s Bill seek to roll back the advances in sexual and reproductive health rights gained by women in South Africa since our democracy.

This was never an easy battle. The debate we ought to be having should not be around frustrating an already difficult process, but rather on how we may ensure that these services are meaningfully accessible to all women, irrespective of age or social status.