Termination of pregnancy policy and services: an appraisal of the implementation and operation of the Choice on Termination of Pregnancy Act (92 of 1996)
Engelbrecht, Michelle Catherine
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The right to decide when to have a child is at the very core of reproductive rights and in essence means that women should have access to safe and effective means of controlling their family size, including contraception and abortion services. Despite this, the WHO estimates that approximately 20 million illegal abortions are performed annually. While the WHO estimates that approximately 20 million illegal abortions are performed annually. While the majority of African countries still have restrictive abortion laws, radical change in abortion legislation occurred in 1996 in South Africa with the passing of the CTOPA. This has generated considerable controversy and the South African health system was faced with the enormous challenge of providing safe, effective, affordable and acceptable TOP services throughout the country. Against this background, research was undertaken to record and analyse the implementation and operation of the CTOPA in the Free State. The literature review was accomplished by consulting relevant legislation, articles in popular and scientific journals as well as newspapers, and the web. The Free State case study entailed the collection of empirical data during a series of interviews in 1998 and 2003 with health workers in general, TOP service providers, TOP clients and key stakeholders. The literature study revealed that the objectives of the CTOPA clearly summarise the intentions of international agreements such as the ICPD, the Beijing Conference and their follow-up reviews. In addition, South Africa has had the advantage of learning from the experiences of the USA and Britain regarding abortion law reform. South Africa has strived to ensure that not only does the law allow for legal abortions, but also that as far as possible additional legislation does not impede access to the service. The CTOPA, together with the commitment of government to provide safe and accessible services, should act as an inspiration to neighbouring countries to reform their abortion laws. With regard to the Free State case study, the following main findings emerged. Despite the slight improvement in the knowledge of health workers regarding the CTOPA, and more positive attitude toward TOP, there was a reluctance to refer women unconditionally to TOP facilities. As time progressed, TOP service providers became more negative in their views of and attitudes toward the service. Little was done to alleviate the situation as counselling and psychological support services remained unavailable for TOP service providers. By 2003, TOP service providers were less likely to evaluate their services as being good, and post-counselling remained illusive for many clients. There were still no facilities providing a 24-hour service; as such, women who were more than twelve weeks pregnant were sent home to initiate the abortion. Furthermore, more women were put onto waiting lists at the TOP facilities when compared to the situation in 1998. Statistics show that TOPs in the Free State have steadily increased, yet only one additional facility became operational in the province while the number of staff providing the service remained constant. The main recommendations included: motivating health managers to become involved with TOP; formulating policies and guidelines for provision of TOP; educating health workers and communities about the CTOPA; implement strategies to address negative attitudes; introducing incentives for TOP service providers; including TOP in the training curriculum of nurses; and making psychological support available for TOP service providers.