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Termination of pregnancy legislation in South Africa: implications for health service providers.

Providing greater access to safe abortion reduces the public health burden of unsafe abortion, which in 2004 was estimated at 68 000 deaths and 5.3 million permanent or temporary disabilities per annum, primarily in developing countries. (1)

The World Health Organization (WHO) defines abortion as a procedure for terminating an unintended pregnancy either by a person without the necessary skills or in an environment without the minimum medical standards or both.

Termination of pregnancy legislation

The advent of democracy in South Africa in 1994 created a unique policy environment for numerous new laws and policies to be legislated, including many within the sphere of women's reproductive health. Major changes in legislation and policy occurred in the area of termination of pregnancy (TOP). The South African Choice on Termination of Pregnancy (CTOP) Act of 1996 replaced the previously restrictive Abortion and Sterilization Act of 1975. The aim of the 1996 legislation was to promote a woman's reproductive right and choice to have an early, safe and legal TOP. As a result of the new TOP legislation, abortion-related morbidity and mortality have decreased significantly by 90%. (2)

The CTOP Amendment Act was first passed in 2004, then challenged in the Constitutional Court owing to a parliamentary process problem. Following nation-wide public hearings was reinstated in 2008. This has resulted in some confusion among health providers. The Amendment Act has, however, now been passed. The Act

* empowers provincial members of executive councils (MECs) of health, instead of the national Minister of Health, to designate abortion-providing facilities and make abortion-related regulations in their provinces

* allows suitably trained registered nurses to perform first-trimester procedures, and

* makes it an offence for a termination to occur at any undesignated facility.

Abortion is a time-restricted health service.

* The CTOP Act provides for abortion on request up to 12 weeks of gestation.

* In cases of socio-economic hardship, rape or incest, and for reasons related to the physical and mental health of the pregnant woman or fetus, terminations can be performed up to 20 weeks' gestation.

* From 20 weeks onward terminations can only be performed under very limited circumstances.

* Parental consent is not required for minors.

* First-trimester TOPs must be performed at a designated health facility by a trained midwife, trained registered nurse, or medical practitioner.

* Second-trimester TOPs must be done by a trained medical practitioner.

A health care provider has the right to refuse to perform an abortion--the right to conscientious objection. However, providers are obliged to inform a woman requesting a TOP of her rights according to the Act. In addition, a conscientious objector is legally and ethically obliged to care for patients with complications arising from an abortion, whether induced or spontaneous.

In 2001 the Medicines Control Council registered mifepristone for abortion use during the first 8 weeks of pregnancy. In combination with misoprostol, it has been shown to be a very effective medical abortion method when used early in the first trimester of pregnancy, and expands a woman's choice of an abortion method. Medical abortion is currently available in the private sector and guidelines are being developed for its introduction into the public health sector.


Despite the new improved legislation, TOP services still remain inaccessible to many women. Barriers to women accessing TOP services include provider opposition to offering services, stigma associated with abortion, poor knowledge of abortion legislation, and a dearth of providers trained to perform abortions and facilities designated to provide abortion services. (3-5) Increasing difficulties in accessing abortion services have resulted in women accessing illegal, unsafe abortions, i.e. outside designated health facilities. (6)

In recent years the number of abortions performed nationally and in each of the provinces has multiplied substantially, indicating increased availability and accessibility to abortion services. (7) Despite this increase in demand and utilisation, challenges exist in the further expansion of services, particularly by trained nurse or midwife service provision up to 12 weeks' gestation. Service provision has been impeded by opposition among health care professionals to abortion services and to those providing them. Furthermore, there is a dearth of health personnel trained to provide abortions. (4) The shortage of health care providers willing or trained to perform abortions undermines the provisions of the CTOP Act by limiting the availability of safe legal abortion, and has serious implications for women's access to safe abortion services and health service planning.

While the new legislation has greatly reduced maternal morbidity and mortality, gaps between policy and implementation need to be addressed. Strategies have to be developed with regard to these gaps in order for TOP legislation to contribute fully to improving women's health in South Africa.

Some of these issues could be addressed by exploring the following:

* An emphasis on quality of care is needed and would encompass all aspects of abortion provision and care. Similarly, the psychosocial needs of providers must be attended to as counselling and support are required for providers and clients.

* Contraceptive counselling, including post-abortion contraceptive counselling, needs to be strengthened.

* Knowledge and understanding around the 1996 CTOP Act, including conscientious objection, need to be strengthened.

* Support programmes and incentive schemes, which attract prospective abortion care providers and retain existing providers, need to be developed.


Associate Director, Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town

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Title Annotation:More about ... Women's health
Author:Harries, Jane
Publication:CME: Your SA Journal of CPD
Geographic Code:6SOUT
Date:Oct 1, 2009
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