View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Cape Town University OpenUCT Abortion services in South Africa: Challenges and barriers to safe abortion care: Health care providers’ perspectives Jane Harries Thesis Presented for the Degree of DOCTOR OF PHILOSOPHY in the Department of Public Health and Family Medicine UNIVERSITY OF CAPE TOWN December 2010 1 ABSTRACT Unsafe abortion is a preventable phenomenon and continues to be a major public health problem in many countries especially in the developing world. Despite abortion being legally available in South Africa after a change in legislation in 1996, barriers to accessing safe abortion services continue to exist. These barriers include provider opposition to abortion, and a shortage of trained and willing abortion providers. The dearth of abortion providers undermines the availability of safe, legal abortion, and has serious implications for women‟s access to abortion services and health service planning. Due to the relatively recent significant changes to abortion legislation in South Africa, little is known formally about the personal and professional attitudes of individuals who are currently working in abortion provision. Exploring the complex factors which determine health care providers‟ involvement or disengagement in services could provide important insights that could inform not only South African policy and service provision, but also that in developing country contexts. A qualitative approach was used which included 48 in-depth interviews, one focus group discussion, and observations with a purposively selected population of abortion related health service providers, managers and policy influentials from the public and NGO sector in the Western Cape Province, South Africa. Data were analyzed using a thematic analysis approach. The computer software package ATLAS ti 5.2 was used to facilitate data sorting and management. Health care providers‟ views and experiences of abortion services were explored from within three domains of enquiry, and included the ways in which individual level, institutional and community contexts impacted on abortion service provision. Health care providers‟ conceptualizations of abortion were influenced by a multiplicity of factors, including personal, moral and religious views, in which abortion was perceived by some as akin to murder or as a sin; whereas others viewed access to safe, legal abortions as an important component of a woman‟s right to ii reproductive autonomy and choice, enabled by the new abortion legislation. Conflict between personal beliefs and professional practice were often mediated by establishing differing thresholds and boundaries in relation to abortion provision. Barriers to service provision included both structural and individual level barriers, and included limited and infrequent abortion and values clarification training opportunities, ambiguity and confusion regarding interpretation and implementation of conscientious objection and its subsequent impact on service provision, and experiences of isolation and stigma in the work place. Failed or poor contraceptive uptake and services were of great concern to providers, underscored by the perception that abortion had in many instances replaced responsible family planning by women requesting abortions. This perception was especially heightened by their experiences of some women returning for repeat or frequent abortions. Fragmented services, functioning and supported by a small dedicated group of abortion providers, who received little professional or emotional support from management or wider health structures, had serious implications for sustaining abortion services. A lack of clear policy guidelines and protocols to guide abortion service delivery further constrained adequate delivery of abortion services. Second trimester abortion services were explored as the contested domain of abortion was the most heightened with second trimester abortions. Many providers struggled to cope with the emotional and visual impact of encountering an aborted fetus. The CTOP Act was significant for women‟s reproductive rights and health, and for overall public health in South Africa. However, the momentum for realizing the full extent of the legislation has been lost since implementation of the Act. In order for this momentum to continue there is an urgent need to address the provider shortage, and abortion education and training needs to be formalized and initiated in medical and nursing schools and should include ongoing training and support for abortion care providers. iii ACKNOWLEDGMENTS I would like to thank the following persons and organizations: My supervisor Dr. Christopher Colvin and co-supervisor Assoc. Prof. Diane Cooper for support and guidance throughout the PhD process The Mellon mentor, Dr. Anna Strebel for support, guidance and sage advice Kathryn Stinson and Phyllis Orner in the School of Public Health and Family Medicine, University of Cape Town Dr. Daniel Grossman at Ibis Reproductive Health, USA and Ms. Naomi Lince and Ms. Adila Hargey at Ibis Reproductive Health, South Africa Dr. Iqbal Shah and Ms. Nicky Sabatini-Fox at the World Health Organization, Geneva, Switzerland for support and facilitating the funding process The Special Program of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland for funding the research project The Medical Research Council of South Africa for additional funding of the research project The Carnegie Corporation, and the Research Office of the University of Cape Town for funding of the PhD completion grant and the opportunity to have time off work to complete the PhD write-up process Dr. Marilet Sienaert, Dr. Mignonne Breier and Dr. Lyn Holness at the Research Office of the University of Cape Town for facilitating and encouraging me to apply for a PhD completion grant, and Ms. Wilna Venter at the Research Office of the University of Cape Town for facilitating the Mellon mentorship support process Colleagues in the Women‟s Health Research Unit School in the School of Public Health and Family Medicine, University of Cape Town Staff in the Western Cape Provincial Department of Health who were willing to share information and assist in facilitating access to health care facilities My parents and family for their ongoing support iv My son Joseph Harries for encouraging me on a daily basis to complete my PhD and for being so understanding about my long absences The many health care providers, managers and policy makers who generously gave of their time and made the research possible The reproductive health NGOs including Marie Stopes International, Ipas South Africa and Mosaic for informative discussions, and who too gave of their time Jane Harries Cape Town December 2010 v LIST OF ACRONYMS AND ABBREVIATIONS ANC African National Congress CEDAW Convention on the Elimination of All Forms of Discrimination against Women CLA Christian Lawyers Association CTOP Act Choice on Termination of Pregnancy Act D&E Dilatation and evacuation DFL Doctors for Life DoH Department of Health EC Emergency contraception FDA Food and Drug Administration GDC Global Doctors for Choice ICPD International Conference on Population and Development IPPF International Planned Parenthood Federation IUD Intrauterine Device MCWH Maternal, Child and Women‟s Health MEC Member of the Executive Council MLP Mid-level Provider MRC Medical Research Council MSI Marie Stopes International MTOP Medical Termination of Pregnancy MVA Manual vacuum aspiration NGO Non-governmental organization PPASA Planned Parenthood Association of South Africa RHRU Reproductive Health Research and HIV Unit RRA Reproductive Rights Alliance SA South Africa SANC South African Nursing Council SRH Sexual and Reproductive Health TOP Termination of Pregnancy USA United States of America USAID United States Agency for International Development vi VC Values Clarification VCAT Values Clarification and Attitude Transformation WHO World Health Organization GLOSSARY OF TERMS Advanced practice clinicians: Includes physician assistants, nurse practitioners and certified nurse midwives. Designated facility: The CTOP Act requires that facilities that provide abortion services be authorized (or designated) to do so by the National Department of Health. Therefore, a designated facility is a hospital or health-care clinic that has submitted an application and been authorized by the National Department of Health to provide abortion services. Manual vacuum aspiration (MVA): An abortion procedure that uses a flexible plastic cannula, which is connected to a manual aspiration syringe with a locking valve to perform a uterine evacuation. In South Africa the procedure is used to perform an abortion up to 12 weeks gestation. It is a relatively simple and quick procedure. Member of the Executive Council: Refers to the Member of the Executive Council of a Province who is responsible for health in that Province. Mid-level provider: A health care professional including nurses, midwives and other non-physician clinicians. Mifepristone: Mifepristone also known as RU 486 is an anti-progestogen drug that causes the gestational sac in early pregnancy, or the embroyo or fetus at subsequent stages, to become detached from the uterine lining. Mifepristone also softens and opens the cervix. In 2001 the South African Medicines Control Council approved a vii regimen of 600mg mifepristone