- Email: [email protected]
The role of advocacy in implementing the South African abortion law
Sanjani Jane Varkey, Sharon Fonn, Mpefe Ketlhapile In order to translate the abortion law in South Africa into services that ensure equity of access and women’s right to control theirbodies, interventions are needed to changejudgemental views on abortion. This paper describes formative research conducted in the Northern Cape Province among 436 community members, 29 women seeking an abortion and 80 health service providers, to develop appropriate interventions to these ends. Based on the findings, two interventions were developed. These interventions appeared to substantially influence personal views by getting people to make a connection between the need for abortion services and the circumstances in which unwanted pregnancies occur. There was a shift towards greater supporf for women’s n’ght to choose in relation to abortion among women community members, though not among men, who resisted this right for married women. Amongstproviders (almost all women) there was an increase in willingness to support service provision and to support staff working in abortion services. These tools could be used in sexuality education in schools and in nursemidwifery/medical training, to complement current advocacy initiatives takingplace atpolicy and programme levels in South Africa, to help to reduce the public health problem of unsafe abortion. Keywords: abortion law and policy, abortion services, advocacy and political process, training of service providers, community peer education, South Africa
N South Africa an estimated 6,000 to 170,000 illegal abortions were conducted in 1989, in comparison to around 700 to 1,100 legal abortions per year in the period 1984-1991,’ with deaths and morbidity resulting from unsafe, induced abortions.2 In the new political climate reform has taken place in many spheres of life, with equity as the cornerstone of transformation in all sectors, including health. The presence of a strong political commitment to women’s rights and the change of the government in 1994, led to the passing of the Choice on the Termination of Pregnancy Act (CTOP), in November 1996. This law guarantees equitable access to abortion services and women’s sole right to control their bodies. It allows midwives to perform first trimester abortions, so as to ensure abortion provision at primary health care level and thus increasing access. Women of all ages, including minors, can request a first trimester abortion regardless of their reasons.3 From February 1997 to January 2000 (last
II
available figures), there has been concerted action to translate the Act into services and a steady increase in the number of abortions reported in public health facilities, rising from 29,326 abortions reported in the first year (Feb97 to Jan-98) to 40,568 (Feb-98 to Jan-99) and to 44,558 (Feb-99 to Jan-00).4 In the first six months after the Act was passed, there were more than double the number of abortions reported in public health facilities compared to the total number of abortions conducted legally during the seven years (1984-1991) prior to the reform.’ Although the Act has undoubtedly niade abortion more available, access for specific groups of women continues to be a problem.5*6 According to the South African Demographic and Health Survey conducted in 1998, only 53 per cent of women were aware that abortions up to 12 weeks of pregnancy were legal.‘,* A higher proportion of young women 15 to 19 years of age (60 per cent), those with no formal schooling (68 per cent) and rural women (61 per cent), did not 103
Varkey, Fonn, Ketlhapile
know that abortions were legal.g Of the 246 public health facilities designated to provide abortion services, less that a third (28 per cent) actually do so. Ninety-nine percent of these facilities are in large cities or towns,lO where 75 per cent of first trimester procedures are conducted. Women are on average 100 kms away from a facility providing abortions, while South African guidelines call for a distance of lo-16 km from primary health care services.‘l The decentralisation of abortion services to primary care level was expected to be slow initially, as midwives needed to be trained in abortion provision. To date, a national training programme has trained some 92 midwives from all nine provinces in vacuum aspiration. The recent Parliamentary hearings, organised by the National Portfolio Committee on Health to assess the progress of implementing abortion services, was a fine example of using political pressure to encourage increased access. Such interventions have successfully led to changes in policies and programmes. With this groundwork in place, it has become important to focus attention on individuals as well, as there appears to be a reluctance amongst providers to provide abortion on request and community members to acknowledge younger women’s right to choose.‘2,13 Greater acceptance of abortion among health managers, providers and community members will help to ensure that equity of access and women’s right to control their bodies become a reality for all South ‘African women.
The research In an assessment of primary health care services in the Northern Cape province of South Africa, the need for assistance in the delivery of abortion services was expressed by health service managers.14 At the request of the Provincial Department of Health to the Women’s Health Project in Johannesburg, it was agreed to conduct a study in order to develop interventions to influence the views of stakeholders in relation to abortion. This paper describes these efforts. Northern Cape comprises one third of the country’s surface area, but has less than two per cent of the country’s population, posing great challenges to service delivery coverage. It also has the second highest teenage pregnancy rate in South Africa.e At the time of data collection in 104
mid-1999, there were two hospitals designated and providing abortions. One hospital provided first and second trimester abortion, with first trimester procedures conducted by trained midwives using vacuum aspiration. In the second hospital, a doctor using the dilation and curettage method was conducting only first trimester abortions. Of the nine midwives trained to provide abortion in the province, three were involved in abortion provision. The rest were either waiting for the service to start in their facility, or had been allocated to another service. An average of 45 abortions were being conducted per month, more than half being first trimester abortions and two-thirds for women aged 18 or older.lO In consultation with the senior management of the Northern Cape Department of Health, two districts, Diamond Field and Kalahari, were selected. Diamond Field district was selected because it included one of the two hospitals designated and providing abortions. In the Kalahari district, one district hospital earmarked to start abortion services was selected for the study. Within this district, a community Health Centre and a clinic that refers patients for abortions were also selected. These four facilities thus represented an abortion referral route. The communities in the catchment areas served by these facilities were included in the study. While the provincial hospital is located in an urban setting, the remaining three sites are in peri-urban areas. Formative researchI was undertaken to document 80 providers‘ and 436 community members’ opinions and knowledge of pregnancy and abortion. At all four study sites, a range of qualitative and quantitative methods were used to collect data. Community members (173) of different ages and both sexes participated in 14 focus group discussions; 263 responded to administered questionnaires. Structured interviews (42) and four focus group discussions with 38 respondents were conducted with providers, including nursing and administrative staff and general assistants. To document the experience of women using the existing abortion services, in-depth interviews were conducted with women who were requesting an abortion or who had undergone an abortion during the site visits. All the data collection instruments were piloted in Gauteng and Northern Cape Province, in English as well as in the local language, with providers
Reproductive
and community groups of various ages and with women who had had abortions. Data collected from the community questionnaires and provider interviews were coded and analysed using the Epi Info Statistical programme. Data from the focus group discussions and in-depth interviews were analysed by a standard means of eliciting common themes, ideas and concepts from responses.16 The most frequently mentioned responses are presented. To obtain women’s opinions on and knowledge of pregnancy and abortion, and the experience of women requesting abortion services, we asked about reasons for unwanted pregnancy, partners’ response to unwanted pregnancy and support for having an abortion on request.
Power imbalances and the nature of sexual relations Power imbalances between men and women was the most frequently mentioned reason for unwanted pregnancy. Most women said that negotiating for safe sex was extremely difficult, resulting in assault, forced sex and desertion. This finding was consistent across age groups. Women said that they had sex even when they did not want to. Both men and women said that men view a woman requesting safe sex as a sign of her infidelity or an admission that she has a sexually transmitted disease. This may explain why negotiating for safer sexual practises is so difficult and why hostile responses are encountered. Interestingly however, similar sanction is not placed on men, which underlines the power imbalance. The degree to which this makes women vulnerable is illustrated in the data from women who had accessed abortion services. Information regarding these women’s relationships was documented in 24/29 cases. Of these 24 women, 14 (58 per cent) reported being in relationships where they were unable to negotiate for protected sex. For one woman, ending her relationship with her boyfriend on learning that he was involved in another relationship resulted in him raping her to retain hold of the relationship. 7 had an argument with my boyfriend and I told him we should end the relationship. He didn’t want to. I was alone when he came over. He
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forced me to have sex with him. At the time I wasn’t using contraceptives and he knew about it. So he forced me and his last words were: “I know when you are pregnant, you will come back to me.“’ (woman requesting abortion, age 24, indepth interview). Access to and control over resources, mostly money, influenced the degree to which women in particular felt able to exercise their rights. In two of the three groups with young girls, the issue of financial support from older men was mentioned as a reason why the women felt they could not negotiate protected sex. This was, however, not mentioned in the focus group discussions with young boys and mentioned in only one of the three groups with adult men. In the interviews with women requesting abortion, many younger women mentioned financial dependency on older men as a reason for having unprotected sex and getting pregnant. Though most often this financial support was due to poverty, and money was needed for basic necessities, on a few occasions it was also an outcome of peer pressure, where the money was spent on ‘luxury’ items.
Barriers to health service use The inaccessibility of contraceptive services was the next most frequently mentioned reason for unplanned pregnancy in the community focus group discussions. Negative provider-client interactions came up often as an issue for the younger women, as well as older women. Some respondents, however, felt that services were easily available. Judgemental provider attitudes were often reiterated in the experiences of women having abortions. This was particularly ascribed to staff at referral centres and on the ward where women having second trimester abortions stayed overnight (this is a ward run by staff not involved in direct abortion care). At referral facilities, women were either denied pregnancy test results or a referral letter, were told that abortion was immoral and sinful, or given misleading information on their eligibility for abortion. In one case, the provider’s description of the procedure was described as biased. “‘Anyway, it is your child which you want to go and be crushed.“She was talking like that so when 105
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I was sitting, I was thinking: But this child is innocent and did not do any wrong that I should come and make it to be killed in such a violent manner.. ’(woman requesting abortion, age 22, in-depth interview) In contrast, the majority of women (28/29) reported that providers who actually conducted the abortions were friendly, helpful and thoughtful, remembered clients the next day and made them feel relaxed and unashamed of their decision to have an abortion. Importantly, however, these same providers felt unsupported and alienated, and said they bore the brunt of their colleagues’ negative attitudes to abortion. ‘Their attitude affects me. At times I tell myself that they are ignorant, why should I be offended. However, at times they break you.’ (abortion provider, interview) When staff were asked their opinion regarding those who provide abortions, the majority (48 per cent) said they were indifferent towards staff involved in abortion services and 26 per cent thought abortion was a wrongful deed, while 26 per cent admired them for the vital and brave roles they played.
Lack of knowledge communities
amongst
Lack of knowledge of reproductive physiology and information on health services dealing with unwanted pregnancy were identified in both the community questionnaires and the community focus groups. In general, people were unaware of or had incorrect information on the most likely time of conception. The majority mentioned that conception could happen any time before or after menstruation. Some felt that pregnancy was more likely to occur in September or March. In the community questionnaires, under half (47 per cent) mentioned that a missed menstruation was the earliest sign of pregnancy, while 47 per cent mentioned signs such as vomiting, weight gain, facial changes, moodiness, change in appetite and breast changes, and 6 per cent did not know any signs of pregnancy at all. The majority of community respondents (83 per cent) were unaware of emergency contra106
ception, and of those who had heard of it, not one was able to provide an adequate description. Just under half of the respondents (44 per cent) were aware that abortion was available on request, but less than a quarter were aware that consent from partners (22 per cent) or parents (20 per cent) was not required.
Partners’ responses pregnancy
to unwanted
Twenty-four of the 29 women who had abortions talked about whether they discussed the abortion decision with anyone. Eighteen of the 24 spoke to someone, of whom 14 spoke to their boyfriend or husband. Twelve of the 18 said that the response to their disclosure was not supportive-desertion (6), abuse (3) and preventing the abortion from happening (1) are examples. The six women who chose not to tell anyone knew that the person concerned would be against the abortion, stop her, desert her or blame her. One woman describes the abuse she faced when telling her boyfriend about the pregnancy. ‘When I told him he slapped me. I fell on the couch, but1 could not get up again. He slapped me again. And he said “Who is the father?” I said “You are the father”. He started to break his CDs and slam the chairs around. I wanted to get out of his house. He pulled me back and slapped me again. I ran oftI’(woman requesting abortion, age 18, in-depth interview) Yet 41 per cent of community members felt that women should get their partners’ consent for an abortion. There appeared to be greater resistance to married women deciding to have an abortion without their husband’s consent than for other women.
Extent of support for abortion request
on
Although the law respects women’s right to control their own bodies by making first trimester abortions available to any woman on request, community and provider opinion favoured abortion under more limited though still quite broad circumstances. Some 55 per cent of community members and providers felt that abortion should be made available on grounds of
Reproductive
rape or incest, or for medical or financial reasons, and for young women. Twenty-two per cent of community members and seven per cent of providers felt that abortion should not be provided under any circumstances. Seven per cent of community members and 36 per cent of providers felt that abortion should be made available on request, regardless of the reason.
Analysis of the formative research findings Sexual pleasure was considered a male preserve by respondents, and they openly discussed rape and violence as a response to women trying to say no to sex, negotiate safer sex or bring up an unwanted pregnancy. There appeared to be a disjuncture between their awareness of this lived reality and their attitudes towards measures to redress this power imbalance, such as women having the legal right to control their own bodies. Our interpretation of this was that individuals did not connect the impact of this power imbalance with their own personal actions. Thus, much as they linked unequal power relations and unwanted pregnancy, respondents did not see the impact of obstructing access to abortion services, being judgemental of providers or of women using abortion services as a means of reinforcing rather than redressing this power imbalance. This interpretation was reinforced when the research data were presented to study participants, who universally responded by saying that they now saw their roles in a different light, e.g. to be more supportive of providers who delivered services. Some said that institutions such as the church also needed to take a different role in this regard. It therefore became obvious that any intervention at both service and community level needed to make a direct link between people’s understanding of gender relations and personal actions. The community intervention also needed to address the lack of knowledge of reproductive physiology. The fact that abortion service providers were being labelled and ostracised is a consequence of the failure to understand that providing abortion services is a means of redressing gender imbalances and a public health intervention. The research indicated that this too needed to be taken up in the provider intervention.
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Developing interventions based on the formative research Following the formative research, two main interventions were developed in partnership with 26 providers in two separate workshops and 50 community members in four separate workshops. The intervention with providers (Health Workers For Change-A) was adapted from Health Workers for Change: A Manual to lmprove Quality of Care,l’ which has proven to be successful in allowing providers to examine and change their attitudes to clients.‘* The community intervention has been called Communities for Choice: Working to Improve Access to Abortion Services. Both interventions consist of a series of workshops, with each workshop having a defined objective and employing a specific activity. The content of each activity, e.g. a roleplay, is not prescribed but generated by the workshop participants based on their own experience. Where appropriate, particularly in the community intervention, this is supplemented by the presentation of information to increase knowledge of reproductive physiology and how to access services for unwanted pregnancy. In the process of developing the Health Workers For Change-A intervention, it transpired that the workshops increased people’s understanding of the link between gender-based power relations and unwanted pregnancy and that this created space to look at preconceived ideas about women requesting and performing abortions. It then became possible to explore how participants could contribute to improving access to services. In a workshop called ‘Women’s Status in Society’, for example, participants created a pictorial depiction of their own upbringing, describing the differential treatment men and women experienced in the household, socially and in the work setting. In the workshop ‘But Why Did Zanele Die?’ participants identified the reasons for unwanted pregnancy. These reasons resonated strongly with the content generated in the ‘Women’s Status in Society’ workshop, and the juxtaposition of the personal with the political became clearer and appeared to forge some degree of empathy and thus an openness to change among the health care providers. The workshop ‘How Do Our Clients and Colleagues See Us?’ encouraged participants to 107
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examine their interaction with clients and coworkers through role-play, in which actors are only given a description of their characters and can generate any content. The situation depicted was of a negative interaction between womanprovider and provider-provider. In the discussion afterwards, when participants were asked why they chose to act in that particular manner, many said that it depicted reality or that they were portraying their actual feelings about the issue. Changes in thinking amongst participants appeared to begin while the role-play itself was in progress. Reflecting on behaviour in a non-threatening environment was shown to be a powerful change technique. The workshop ‘Rights and Responsibilities’ uses a debate format for providers to discuss their own interpretation of their rights and responsibilities in relation to abortion services. One group is asked to defend the premise that providers who have a moral objection to abortion need not get involved in service delivery. A second group is asked to defend the position that, regardless of one’s personal opinion, providers have a professional responsibility to fulfil regarding abortion services. Participants are given a choice as to which ‘side’ they would prefer to defend, which they can do as long as there is an equal number of participants for the two groups. The debate format forces participants to convince their opponents of their arguments. At times, participants would put forward arguments in the debate that conflicted with their own personal opinions. For example, participants who normally equate abortion with taking away the life of a fetus would, in the debate, argue that by obstructing access, providers were taking away the life of a woman. The workshop facilitators felt that the dynamic of individuals voicing an opinion that they themselves normally do not hear offered an opportunity to re-examine those opinions in a non-directive and playful format. Following the debate, participants defined their rights and responsibilities. Included in their list of rights was the option not to get involved in what they considered as ‘direct abortion care’, which was defined as conducting the actual procedure, counselling and emotional support during and after the procedure. Their list of responsibilities included that, at a minimum, all 108
providers had to get involved in ‘indirect abortion care’, e.g. for nursing and other non-nursing staff responsibilities. They defined indirect abortion care as giving women correct information referring to appropriate facilities and routine patient observation. Other responsibilities included respecting women’s right to make choices over their bodies, maintaining the wellbeing and health of women, not obstructing women’s access to abortion services and supporting staff involved in the provision of abortion services. Similar processes operated in the intervention with community members. Role-play, by allowing people to act or pretend to be someone else, appeared to help participants to imagine the feelings, thoughts and actions of women when faced with an unwanted pregnancy. Empathy seems to have been a motivating factor in promoting a change in attitudes. The role-plays also generated some degree of conflict. The one which focused on a marrie woman wanting an d abortion resulted in heated debate between male participants, some supporting women’s right to make autonomous decisions and others opposing it. This showed that both empathy and conflict can co-exist amongst participants, and that both may be potent catalysts for change. The presentation of more didactic information in the Communities for Choice intervention attempts to make learning fun and uses drawings to explain the signs of pregnancy, posters to explain the abortion procedure, collecting a certain number of leaves, sticks and stones to explain when emergency contraception can be used and the period of weeks of pregnancy during which particular abortion methods can be used.
Testing the interventions The interventions were carried out with a sample of community members and providers, and identical pre- and post- intervention questionnaires were administered to assess the immediate impact. Sixty-eight community members (12 women, 19 men, 19 young boys and 18 young girls) took part in four intervention workshops. Participants were recruited by individuals living in the particular community where the workshops were conducted and who were regarded as commun-
Reproductive
ity leaders. The questionnaire asked about their opinions on abortion and on women having abortions, knowledge of when and how conception occurs, and awareness of the abortion law. (Table 1) Where differences between male and female community members existed, these are shown. In the community group, changes in views occurred for every indicator. There was increased support for abortion on request and for minors’ right to give sole consent for abortion, and less anger towards women who seek abortions. There was also greater knowledge that abortion was available on request up to 12 weeks, that a missed period is an early sign of pregnancy and that conception usually occurs mid-cycle. Only on the question of married women’s right to consent to abortion on their own was there a different trend - more women supported this than before, whereas fewer men did. In the evaluation of the provider intervention, a representative group of 11 providers (10 women and one man) participated from all professional categories at hospital and clinic level, selected by the manager in-charge of the health facility in which the intervention was conducted.lg There were increases in support for abortion on request, support for both minors’ and married women’s right to give sole consent and
Table 1. Pre- and post-intervention
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more respect for providers of abortion services. All 11 staff were asked before and after the intervention whether they were willing to get involved in improving abortion services; only professional nurses were asked if they were prepared to perform abortions, while both enrolled and professional nurses were asked if they were prepared to refer patients for abortions. These questions reflected what they would be trained for if they agreed to do abortion service work. All but one provider expressed greater openness to being involved in abortion services, all enrolled nurses and professional nurses were willing to refer patients for abortions and one professional nurse was willing to perform abortions. While these pilot tests are limited and further assessment is required, certain trends are obvious. The shift towards greater support for women’s right to choose in relation to abortion as a result of participating in these interventions is promising. Amongst providers it may be significant to those who are currently involved in abortion provision that this intervention appears to increase the willingness to support these staff. The willingness reported by the one nurse to perform abortions was heartening, an important shift for someone to make in a short space of time. At the community level the workshops managed to raise debate about power and sex and reproductive health, and women’s views as
views of community members (n=68)
Changes in attitude and information regarding abortion and pregnancy
Pre-intervention
Post-intervention
Number
%
Number
%
Supports abortion on request
13
19%
37
54%
Supports married women’s
16
24%
26
41%
10
26%
7
18%
6
20%
21
JO% 51%
right to sole consent for abortion
-men
-women Supports
minors' sole
16
26%
35
Anger towards women seeking abortion
right to consent for abortion
24
35%
6
9%
Knows that abortion
42
62%
63
93%
Knows of minors’ sole right to consent for abortion
16
24%
56
65%
Knows that missed period is the earliest sign of pregnancy
13
19%
35
51%
-men
4
11%
13
34%
-women
9
30%
22
73%
is available
on request
1
1%
33
49%
-men
1
3%
13
34%
-women
_
0
20
67%
Knows that conception
20013
likely to happen 14 days after menstruation
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Fonn, Ketlhapile
both community members and as health service providers did change substantially as a result. In spite of the interventions, however, the men from the community continued to find it difficult to agree that women would want to take decisions on their own, when they perceive such decisions to be within their own jurisdiction of power. To bring about more changes in this regard, longerin term interventions such as sexuality education schools and collaborative campaigns between government sectors of health and education will be required.
Conclusion This research-action project successfully explored knowledge and attitudes towards abortion in the community and among health service providers in the Northern Cape Province through interventions to reduce barriers to implementing policy on abortion and increase access to abortion services. While requiring further assessment, Health Workers for Change - Working to Improve the Quality of Abortion Services and Communities for Choice - Working to Improve Access to Abortion Services appear to be useful
interventions and will be available for others wishing to use and test them.20 The interventions could serve as tools that can be integrated into the education curriculum of schools and nursemidwifery/medical training respectively. Interventions to influence personal views are an important adjunct to advocacy initiatives. This is the case when attempting to build a lobby for policy change and in moving from policy development to policy implementation. Acknowledgments The authors would like to thank all staff and community members of the Northern Cape, especially Marian Loveday, who supported this project; Health Systems Trust and Public Welfare Foundation for their financial support; and Khin San Tint, Ellen Roberston, Ndivhuwo Masindi, Nonhlanhla Makhanya and TK Sundari Ravindran for their support and insights during different phases of the project. Correspondence Sharon Fonn, Women’s Health Project, PO Box 1038, Johannesburg2000, South Africa. Fax: 27-l l489-9922. E-mail: [email protected]
References and Notes 1. Kustner HGV (ed), 1991.
Epidemiological Comments. 18(10). Department of National Health and Population Development, Pretoria. 2. Rees H, Katzenellenbogen J, Shabodien R et al, 1997. The epidemiology of incomplete abortion in South Africa. South African Medical Journal. 87:4323.
Choice on Termination of Pregnancy Act 92 of 1996. 4. Barometer. Reproductive Rights Alliance. (In press) 5. Varkey SJ and Fonn S, 1999. How far are we? Assessing the implementation of abortion services: A review of literature and work-in-progress. Health Systems Trust, Durban. 6. See also: Varkey SJ and Form S, 2000. Termination of Pregnancy. South African Health Review.
Crisp N, Ntuli A (eds). Health 110
Systems Trust, Durban. 7. Kola S, Budlender D, Kimmie 2 et al, 1999. A Gender Survey. Conducted for the Commission on Gender Equality. South Africa. 8. South African Demographic and Health Survey 2998. Department of Health, Medical Research Council and MACR. Preliminary report. 9. South African Demographic and Health Survey 2998. Department of Health, Medical Research Council and MACR. (In press) 10. Braam T (ed), 1998. Barometer Z(2). Reproductive Rights Alliance, Johannesburg. 11. Rispel L, Price M, Cabral J et al, 1996. ConfrontingNeed and Affordability: Guidelines for Primary Health Care Services in South Africa. Centre for Health
Policy, Department of Community Health, University
of Witwatersrand,
South Africa. ET, Lurie M et al. Barriers to implementing South Africa’s Termination of Pregnancy Act: A case study from rural KwaZulu/Natal province. Centre for Epidemiological Research in South Africa (CERSAYHlabisa, Medical Research Council, South Africa. (Draft) 13 Engelbrecht M, Pelser A, Ngwenya C et al, 1999. A Project 12 Harrison A, Montgomery
Management Strategy to Overcome Impediments to the Operation of the Choice on Termination ofpregnancy Act of 1996 in the Free State: Findings from the Survey. Centre for
Health Systems Research and Development, University of the Orange Free State, South Africa. 14. Fonn S, Xaba M, Tint KS et al,
Reproductive
1998.Transforming Reproductive Health Services: Results from a Multi-Faceted Research and Implementation Process from Three South African Provinces. Women’s Health Project, Johannesburg. 15 Details of the methodology are available from the Women’s Health Project on request. 16. Dawson S, Manderson L, Tallo V, 1992. The Focus Group Manual. Methods for Social Research in Tropical Diseases.
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No 1. UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases. Geneva. 17. Fonn S, Xaba M. 1995. Health Workers for Change: A Manual to Improve Quality of Care. Women’s Health Project, South Africa and UNDP/World Bank/WHO. Geneva. 18. Washington 00, Laisser R, Mbilima M et al. The impact of Health Workers for Change in seven settings: a useful
management and health system development tool. Health Policy and Planning. (In press) 19. Very few men take up nursing as a profession in South Africa. This 1O:l sex ratio reflects the sex ratio in both nursing and administrative jobs in the province. 20. The published interventions will be available in early 2001 from the Women’s Health Project.
R&sum6
Resumh
Afin que la loi sur l’avortement
Para que la ley de abort0 en Sudafrica se traduzca en servicios que aseguren la equidad de acceso y el derecho de la mujer de controlar su cuerpo, se precisan intervenciones dirigidas a cambiar las attitudes negativas hacia el aborto. Este trabajo describe una investigacidn formativa realizada en la Provincia de1 Cabo Norte, en la cual participaron 436 integrantes de la comunidad, 29 mujeres que querian abortar, y 80 proveedores de servicios de la salud. En base a 10s resultados, se efectuaron dos intervenciones, las cuales parecian tener bastante influencia sobre las attitudes de las personas al lograr que ellas vincularan la necesidad de servicios de abort0 con las circunstancias en que ocurren 10s embarazos no planificados. Entre las mujeres de la comunidad, hubo mayor apoyo para el derecho de la mujer de optar a abortar, pero no asi entre 10s hombres, quienes se opusieron a este derecho para las mujeres casadas. Entre 10s proveedores (casi todas mujeres), aumentd su disposition a favor de apoyar tanto la provision de servicios coma el personal que trabaja en dichos servicios. Estas herramientas podrian usarse en la education sexual escolar y en la capacitation de medicos y parteras profesionales, corn0 complement0 a las iniciativas politicas y programaticas en curso en Sudafrica, para ayudar a reducir el problema de salud publica que es el abort0 practicado en condiciones de riesgo.
en Afrique du Sud se traduise en services assurant l’egalite d’accbs et le droit des femmes a maitriser leur corps, il est necessaire de modifier les opinions negatives sur l’avortement. L’article decrit la recherche formative me&e dans la province du Cap-Nord parmi 436 membres de la communaute, 29 femmes souhaitant avorter et 80 praticiens de soins de Sante, pour elaborer des interventions approprices. Deux interventions ont ete mises au point en fonction des conclusions et elles ont influence sensiblement les opinions personnelles en incitant les gens a mettre en rapport la necessite de services d’avortement et les circonstances dans lesquelles les grossesses non d&i&es se produisent. Dans la communaute, on a note que les femmes appuyaient davantage le droit des femmes a avoir le choix en mat&-e d’avortement, contrairement aux hommes, qui refutent ce droit pour les femmes mariees. Les praticiens (des femmes pour la plupart) etaient plus desireux de soutenir la prestation de services et seconder le personnel travaillant dans les services d’avortement. Ces outils pourraient &tre utilises dans l’education sexuelle en milieu scolaire et dans la formation des medecins et infirmieresksages femmes pour completer les initiatives de plaidoyer mises en ceuvre actuellement aux niveaux des politiques et des programmes en Afrique du Sud, en vue de reduire le probleme de Sante publique pose par les avortements non medicalises.
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N South Africa an estimated 6,000 to 170,000 illegal abortions were conducted in 1989, in comparison to around 700 to 1,100 legal abortions per year in the period 1984-1991,’ with deaths and morbidity resulting from unsafe, induced abortions.2 In the new political climate reform has taken place in many spheres of life, with equity as the cornerstone of transformation in all sectors, including health. The presence of a strong political commitment to women’s rights and the change of the government in 1994, led to the passing of the Choice on the Termination of Pregnancy Act (CTOP), in November 1996. This law guarantees equitable access to abortion services and women’s sole right to control their bodies. It allows midwives to perform first trimester abortions, so as to ensure abortion provision at primary health care level and thus increasing access. Women of all ages, including minors, can request a first trimester abortion regardless of their reasons.3 From February 1997 to January 2000 (last
II
available figures), there has been concerted action to translate the Act into services and a steady increase in the number of abortions reported in public health facilities, rising from 29,326 abortions reported in the first year (Feb97 to Jan-98) to 40,568 (Feb-98 to Jan-99) and to 44,558 (Feb-99 to Jan-00).4 In the first six months after the Act was passed, there were more than double the number of abortions reported in public health facilities compared to the total number of abortions conducted legally during the seven years (1984-1991) prior to the reform.’ Although the Act has undoubtedly niade abortion more available, access for specific groups of women continues to be a problem.5*6 According to the South African Demographic and Health Survey conducted in 1998, only 53 per cent of women were aware that abortions up to 12 weeks of pregnancy were legal.‘,* A higher proportion of young women 15 to 19 years of age (60 per cent), those with no formal schooling (68 per cent) and rural women (61 per cent), did not 103
Varkey, Fonn, Ketlhapile
know that abortions were legal.g Of the 246 public health facilities designated to provide abortion services, less that a third (28 per cent) actually do so. Ninety-nine percent of these facilities are in large cities or towns,lO where 75 per cent of first trimester procedures are conducted. Women are on average 100 kms away from a facility providing abortions, while South African guidelines call for a distance of lo-16 km from primary health care services.‘l The decentralisation of abortion services to primary care level was expected to be slow initially, as midwives needed to be trained in abortion provision. To date, a national training programme has trained some 92 midwives from all nine provinces in vacuum aspiration. The recent Parliamentary hearings, organised by the National Portfolio Committee on Health to assess the progress of implementing abortion services, was a fine example of using political pressure to encourage increased access. Such interventions have successfully led to changes in policies and programmes. With this groundwork in place, it has become important to focus attention on individuals as well, as there appears to be a reluctance amongst providers to provide abortion on request and community members to acknowledge younger women’s right to choose.‘2,13 Greater acceptance of abortion among health managers, providers and community members will help to ensure that equity of access and women’s right to control their bodies become a reality for all South ‘African women.
The research In an assessment of primary health care services in the Northern Cape province of South Africa, the need for assistance in the delivery of abortion services was expressed by health service managers.14 At the request of the Provincial Department of Health to the Women’s Health Project in Johannesburg, it was agreed to conduct a study in order to develop interventions to influence the views of stakeholders in relation to abortion. This paper describes these efforts. Northern Cape comprises one third of the country’s surface area, but has less than two per cent of the country’s population, posing great challenges to service delivery coverage. It also has the second highest teenage pregnancy rate in South Africa.e At the time of data collection in 104
mid-1999, there were two hospitals designated and providing abortions. One hospital provided first and second trimester abortion, with first trimester procedures conducted by trained midwives using vacuum aspiration. In the second hospital, a doctor using the dilation and curettage method was conducting only first trimester abortions. Of the nine midwives trained to provide abortion in the province, three were involved in abortion provision. The rest were either waiting for the service to start in their facility, or had been allocated to another service. An average of 45 abortions were being conducted per month, more than half being first trimester abortions and two-thirds for women aged 18 or older.lO In consultation with the senior management of the Northern Cape Department of Health, two districts, Diamond Field and Kalahari, were selected. Diamond Field district was selected because it included one of the two hospitals designated and providing abortions. In the Kalahari district, one district hospital earmarked to start abortion services was selected for the study. Within this district, a community Health Centre and a clinic that refers patients for abortions were also selected. These four facilities thus represented an abortion referral route. The communities in the catchment areas served by these facilities were included in the study. While the provincial hospital is located in an urban setting, the remaining three sites are in peri-urban areas. Formative researchI was undertaken to document 80 providers‘ and 436 community members’ opinions and knowledge of pregnancy and abortion. At all four study sites, a range of qualitative and quantitative methods were used to collect data. Community members (173) of different ages and both sexes participated in 14 focus group discussions; 263 responded to administered questionnaires. Structured interviews (42) and four focus group discussions with 38 respondents were conducted with providers, including nursing and administrative staff and general assistants. To document the experience of women using the existing abortion services, in-depth interviews were conducted with women who were requesting an abortion or who had undergone an abortion during the site visits. All the data collection instruments were piloted in Gauteng and Northern Cape Province, in English as well as in the local language, with providers
Reproductive
and community groups of various ages and with women who had had abortions. Data collected from the community questionnaires and provider interviews were coded and analysed using the Epi Info Statistical programme. Data from the focus group discussions and in-depth interviews were analysed by a standard means of eliciting common themes, ideas and concepts from responses.16 The most frequently mentioned responses are presented. To obtain women’s opinions on and knowledge of pregnancy and abortion, and the experience of women requesting abortion services, we asked about reasons for unwanted pregnancy, partners’ response to unwanted pregnancy and support for having an abortion on request.
Power imbalances and the nature of sexual relations Power imbalances between men and women was the most frequently mentioned reason for unwanted pregnancy. Most women said that negotiating for safe sex was extremely difficult, resulting in assault, forced sex and desertion. This finding was consistent across age groups. Women said that they had sex even when they did not want to. Both men and women said that men view a woman requesting safe sex as a sign of her infidelity or an admission that she has a sexually transmitted disease. This may explain why negotiating for safer sexual practises is so difficult and why hostile responses are encountered. Interestingly however, similar sanction is not placed on men, which underlines the power imbalance. The degree to which this makes women vulnerable is illustrated in the data from women who had accessed abortion services. Information regarding these women’s relationships was documented in 24/29 cases. Of these 24 women, 14 (58 per cent) reported being in relationships where they were unable to negotiate for protected sex. For one woman, ending her relationship with her boyfriend on learning that he was involved in another relationship resulted in him raping her to retain hold of the relationship. 7 had an argument with my boyfriend and I told him we should end the relationship. He didn’t want to. I was alone when he came over. He
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forced me to have sex with him. At the time I wasn’t using contraceptives and he knew about it. So he forced me and his last words were: “I know when you are pregnant, you will come back to me.“’ (woman requesting abortion, age 24, indepth interview). Access to and control over resources, mostly money, influenced the degree to which women in particular felt able to exercise their rights. In two of the three groups with young girls, the issue of financial support from older men was mentioned as a reason why the women felt they could not negotiate protected sex. This was, however, not mentioned in the focus group discussions with young boys and mentioned in only one of the three groups with adult men. In the interviews with women requesting abortion, many younger women mentioned financial dependency on older men as a reason for having unprotected sex and getting pregnant. Though most often this financial support was due to poverty, and money was needed for basic necessities, on a few occasions it was also an outcome of peer pressure, where the money was spent on ‘luxury’ items.
Barriers to health service use The inaccessibility of contraceptive services was the next most frequently mentioned reason for unplanned pregnancy in the community focus group discussions. Negative provider-client interactions came up often as an issue for the younger women, as well as older women. Some respondents, however, felt that services were easily available. Judgemental provider attitudes were often reiterated in the experiences of women having abortions. This was particularly ascribed to staff at referral centres and on the ward where women having second trimester abortions stayed overnight (this is a ward run by staff not involved in direct abortion care). At referral facilities, women were either denied pregnancy test results or a referral letter, were told that abortion was immoral and sinful, or given misleading information on their eligibility for abortion. In one case, the provider’s description of the procedure was described as biased. “‘Anyway, it is your child which you want to go and be crushed.“She was talking like that so when 105
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I was sitting, I was thinking: But this child is innocent and did not do any wrong that I should come and make it to be killed in such a violent manner.. ’(woman requesting abortion, age 22, in-depth interview) In contrast, the majority of women (28/29) reported that providers who actually conducted the abortions were friendly, helpful and thoughtful, remembered clients the next day and made them feel relaxed and unashamed of their decision to have an abortion. Importantly, however, these same providers felt unsupported and alienated, and said they bore the brunt of their colleagues’ negative attitudes to abortion. ‘Their attitude affects me. At times I tell myself that they are ignorant, why should I be offended. However, at times they break you.’ (abortion provider, interview) When staff were asked their opinion regarding those who provide abortions, the majority (48 per cent) said they were indifferent towards staff involved in abortion services and 26 per cent thought abortion was a wrongful deed, while 26 per cent admired them for the vital and brave roles they played.
Lack of knowledge communities
amongst
Lack of knowledge of reproductive physiology and information on health services dealing with unwanted pregnancy were identified in both the community questionnaires and the community focus groups. In general, people were unaware of or had incorrect information on the most likely time of conception. The majority mentioned that conception could happen any time before or after menstruation. Some felt that pregnancy was more likely to occur in September or March. In the community questionnaires, under half (47 per cent) mentioned that a missed menstruation was the earliest sign of pregnancy, while 47 per cent mentioned signs such as vomiting, weight gain, facial changes, moodiness, change in appetite and breast changes, and 6 per cent did not know any signs of pregnancy at all. The majority of community respondents (83 per cent) were unaware of emergency contra106
ception, and of those who had heard of it, not one was able to provide an adequate description. Just under half of the respondents (44 per cent) were aware that abortion was available on request, but less than a quarter were aware that consent from partners (22 per cent) or parents (20 per cent) was not required.
Partners’ responses pregnancy
to unwanted
Twenty-four of the 29 women who had abortions talked about whether they discussed the abortion decision with anyone. Eighteen of the 24 spoke to someone, of whom 14 spoke to their boyfriend or husband. Twelve of the 18 said that the response to their disclosure was not supportive-desertion (6), abuse (3) and preventing the abortion from happening (1) are examples. The six women who chose not to tell anyone knew that the person concerned would be against the abortion, stop her, desert her or blame her. One woman describes the abuse she faced when telling her boyfriend about the pregnancy. ‘When I told him he slapped me. I fell on the couch, but1 could not get up again. He slapped me again. And he said “Who is the father?” I said “You are the father”. He started to break his CDs and slam the chairs around. I wanted to get out of his house. He pulled me back and slapped me again. I ran oftI’(woman requesting abortion, age 18, in-depth interview) Yet 41 per cent of community members felt that women should get their partners’ consent for an abortion. There appeared to be greater resistance to married women deciding to have an abortion without their husband’s consent than for other women.
Extent of support for abortion request
on
Although the law respects women’s right to control their own bodies by making first trimester abortions available to any woman on request, community and provider opinion favoured abortion under more limited though still quite broad circumstances. Some 55 per cent of community members and providers felt that abortion should be made available on grounds of
Reproductive
rape or incest, or for medical or financial reasons, and for young women. Twenty-two per cent of community members and seven per cent of providers felt that abortion should not be provided under any circumstances. Seven per cent of community members and 36 per cent of providers felt that abortion should be made available on request, regardless of the reason.
Analysis of the formative research findings Sexual pleasure was considered a male preserve by respondents, and they openly discussed rape and violence as a response to women trying to say no to sex, negotiate safer sex or bring up an unwanted pregnancy. There appeared to be a disjuncture between their awareness of this lived reality and their attitudes towards measures to redress this power imbalance, such as women having the legal right to control their own bodies. Our interpretation of this was that individuals did not connect the impact of this power imbalance with their own personal actions. Thus, much as they linked unequal power relations and unwanted pregnancy, respondents did not see the impact of obstructing access to abortion services, being judgemental of providers or of women using abortion services as a means of reinforcing rather than redressing this power imbalance. This interpretation was reinforced when the research data were presented to study participants, who universally responded by saying that they now saw their roles in a different light, e.g. to be more supportive of providers who delivered services. Some said that institutions such as the church also needed to take a different role in this regard. It therefore became obvious that any intervention at both service and community level needed to make a direct link between people’s understanding of gender relations and personal actions. The community intervention also needed to address the lack of knowledge of reproductive physiology. The fact that abortion service providers were being labelled and ostracised is a consequence of the failure to understand that providing abortion services is a means of redressing gender imbalances and a public health intervention. The research indicated that this too needed to be taken up in the provider intervention.
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Developing interventions based on the formative research Following the formative research, two main interventions were developed in partnership with 26 providers in two separate workshops and 50 community members in four separate workshops. The intervention with providers (Health Workers For Change-A) was adapted from Health Workers for Change: A Manual to lmprove Quality of Care,l’ which has proven to be successful in allowing providers to examine and change their attitudes to clients.‘* The community intervention has been called Communities for Choice: Working to Improve Access to Abortion Services. Both interventions consist of a series of workshops, with each workshop having a defined objective and employing a specific activity. The content of each activity, e.g. a roleplay, is not prescribed but generated by the workshop participants based on their own experience. Where appropriate, particularly in the community intervention, this is supplemented by the presentation of information to increase knowledge of reproductive physiology and how to access services for unwanted pregnancy. In the process of developing the Health Workers For Change-A intervention, it transpired that the workshops increased people’s understanding of the link between gender-based power relations and unwanted pregnancy and that this created space to look at preconceived ideas about women requesting and performing abortions. It then became possible to explore how participants could contribute to improving access to services. In a workshop called ‘Women’s Status in Society’, for example, participants created a pictorial depiction of their own upbringing, describing the differential treatment men and women experienced in the household, socially and in the work setting. In the workshop ‘But Why Did Zanele Die?’ participants identified the reasons for unwanted pregnancy. These reasons resonated strongly with the content generated in the ‘Women’s Status in Society’ workshop, and the juxtaposition of the personal with the political became clearer and appeared to forge some degree of empathy and thus an openness to change among the health care providers. The workshop ‘How Do Our Clients and Colleagues See Us?’ encouraged participants to 107
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examine their interaction with clients and coworkers through role-play, in which actors are only given a description of their characters and can generate any content. The situation depicted was of a negative interaction between womanprovider and provider-provider. In the discussion afterwards, when participants were asked why they chose to act in that particular manner, many said that it depicted reality or that they were portraying their actual feelings about the issue. Changes in thinking amongst participants appeared to begin while the role-play itself was in progress. Reflecting on behaviour in a non-threatening environment was shown to be a powerful change technique. The workshop ‘Rights and Responsibilities’ uses a debate format for providers to discuss their own interpretation of their rights and responsibilities in relation to abortion services. One group is asked to defend the premise that providers who have a moral objection to abortion need not get involved in service delivery. A second group is asked to defend the position that, regardless of one’s personal opinion, providers have a professional responsibility to fulfil regarding abortion services. Participants are given a choice as to which ‘side’ they would prefer to defend, which they can do as long as there is an equal number of participants for the two groups. The debate format forces participants to convince their opponents of their arguments. At times, participants would put forward arguments in the debate that conflicted with their own personal opinions. For example, participants who normally equate abortion with taking away the life of a fetus would, in the debate, argue that by obstructing access, providers were taking away the life of a woman. The workshop facilitators felt that the dynamic of individuals voicing an opinion that they themselves normally do not hear offered an opportunity to re-examine those opinions in a non-directive and playful format. Following the debate, participants defined their rights and responsibilities. Included in their list of rights was the option not to get involved in what they considered as ‘direct abortion care’, which was defined as conducting the actual procedure, counselling and emotional support during and after the procedure. Their list of responsibilities included that, at a minimum, all 108
providers had to get involved in ‘indirect abortion care’, e.g. for nursing and other non-nursing staff responsibilities. They defined indirect abortion care as giving women correct information referring to appropriate facilities and routine patient observation. Other responsibilities included respecting women’s right to make choices over their bodies, maintaining the wellbeing and health of women, not obstructing women’s access to abortion services and supporting staff involved in the provision of abortion services. Similar processes operated in the intervention with community members. Role-play, by allowing people to act or pretend to be someone else, appeared to help participants to imagine the feelings, thoughts and actions of women when faced with an unwanted pregnancy. Empathy seems to have been a motivating factor in promoting a change in attitudes. The role-plays also generated some degree of conflict. The one which focused on a marrie woman wanting an d abortion resulted in heated debate between male participants, some supporting women’s right to make autonomous decisions and others opposing it. This showed that both empathy and conflict can co-exist amongst participants, and that both may be potent catalysts for change. The presentation of more didactic information in the Communities for Choice intervention attempts to make learning fun and uses drawings to explain the signs of pregnancy, posters to explain the abortion procedure, collecting a certain number of leaves, sticks and stones to explain when emergency contraception can be used and the period of weeks of pregnancy during which particular abortion methods can be used.
Testing the interventions The interventions were carried out with a sample of community members and providers, and identical pre- and post- intervention questionnaires were administered to assess the immediate impact. Sixty-eight community members (12 women, 19 men, 19 young boys and 18 young girls) took part in four intervention workshops. Participants were recruited by individuals living in the particular community where the workshops were conducted and who were regarded as commun-
Reproductive
ity leaders. The questionnaire asked about their opinions on abortion and on women having abortions, knowledge of when and how conception occurs, and awareness of the abortion law. (Table 1) Where differences between male and female community members existed, these are shown. In the community group, changes in views occurred for every indicator. There was increased support for abortion on request and for minors’ right to give sole consent for abortion, and less anger towards women who seek abortions. There was also greater knowledge that abortion was available on request up to 12 weeks, that a missed period is an early sign of pregnancy and that conception usually occurs mid-cycle. Only on the question of married women’s right to consent to abortion on their own was there a different trend - more women supported this than before, whereas fewer men did. In the evaluation of the provider intervention, a representative group of 11 providers (10 women and one man) participated from all professional categories at hospital and clinic level, selected by the manager in-charge of the health facility in which the intervention was conducted.lg There were increases in support for abortion on request, support for both minors’ and married women’s right to give sole consent and
Table 1. Pre- and post-intervention
Health Matters, Vol. 8, No. 16, November
more respect for providers of abortion services. All 11 staff were asked before and after the intervention whether they were willing to get involved in improving abortion services; only professional nurses were asked if they were prepared to perform abortions, while both enrolled and professional nurses were asked if they were prepared to refer patients for abortions. These questions reflected what they would be trained for if they agreed to do abortion service work. All but one provider expressed greater openness to being involved in abortion services, all enrolled nurses and professional nurses were willing to refer patients for abortions and one professional nurse was willing to perform abortions. While these pilot tests are limited and further assessment is required, certain trends are obvious. The shift towards greater support for women’s right to choose in relation to abortion as a result of participating in these interventions is promising. Amongst providers it may be significant to those who are currently involved in abortion provision that this intervention appears to increase the willingness to support these staff. The willingness reported by the one nurse to perform abortions was heartening, an important shift for someone to make in a short space of time. At the community level the workshops managed to raise debate about power and sex and reproductive health, and women’s views as
views of community members (n=68)
Changes in attitude and information regarding abortion and pregnancy
Pre-intervention
Post-intervention
Number
%
Number
%
Supports abortion on request
13
19%
37
54%
Supports married women’s
16
24%
26
41%
10
26%
7
18%
6
20%
21
JO% 51%
right to sole consent for abortion
-men
-women Supports
minors' sole
16
26%
35
Anger towards women seeking abortion
right to consent for abortion
24
35%
6
9%
Knows that abortion
42
62%
63
93%
Knows of minors’ sole right to consent for abortion
16
24%
56
65%
Knows that missed period is the earliest sign of pregnancy
13
19%
35
51%
-men
4
11%
13
34%
-women
9
30%
22
73%
is available
on request
1
1%
33
49%
-men
1
3%
13
34%
-women
_
0
20
67%
Knows that conception
20013
likely to happen 14 days after menstruation
109
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Fonn, Ketlhapile
both community members and as health service providers did change substantially as a result. In spite of the interventions, however, the men from the community continued to find it difficult to agree that women would want to take decisions on their own, when they perceive such decisions to be within their own jurisdiction of power. To bring about more changes in this regard, longerin term interventions such as sexuality education schools and collaborative campaigns between government sectors of health and education will be required.
Conclusion This research-action project successfully explored knowledge and attitudes towards abortion in the community and among health service providers in the Northern Cape Province through interventions to reduce barriers to implementing policy on abortion and increase access to abortion services. While requiring further assessment, Health Workers for Change - Working to Improve the Quality of Abortion Services and Communities for Choice - Working to Improve Access to Abortion Services appear to be useful
interventions and will be available for others wishing to use and test them.20 The interventions could serve as tools that can be integrated into the education curriculum of schools and nursemidwifery/medical training respectively. Interventions to influence personal views are an important adjunct to advocacy initiatives. This is the case when attempting to build a lobby for policy change and in moving from policy development to policy implementation. Acknowledgments The authors would like to thank all staff and community members of the Northern Cape, especially Marian Loveday, who supported this project; Health Systems Trust and Public Welfare Foundation for their financial support; and Khin San Tint, Ellen Roberston, Ndivhuwo Masindi, Nonhlanhla Makhanya and TK Sundari Ravindran for their support and insights during different phases of the project. Correspondence Sharon Fonn, Women’s Health Project, PO Box 1038, Johannesburg2000, South Africa. Fax: 27-l l489-9922. E-mail: [email protected]
References and Notes 1. Kustner HGV (ed), 1991.
Epidemiological Comments. 18(10). Department of National Health and Population Development, Pretoria. 2. Rees H, Katzenellenbogen J, Shabodien R et al, 1997. The epidemiology of incomplete abortion in South Africa. South African Medical Journal. 87:4323.
Choice on Termination of Pregnancy Act 92 of 1996. 4. Barometer. Reproductive Rights Alliance. (In press) 5. Varkey SJ and Fonn S, 1999. How far are we? Assessing the implementation of abortion services: A review of literature and work-in-progress. Health Systems Trust, Durban. 6. See also: Varkey SJ and Form S, 2000. Termination of Pregnancy. South African Health Review.
Crisp N, Ntuli A (eds). Health 110
Systems Trust, Durban. 7. Kola S, Budlender D, Kimmie 2 et al, 1999. A Gender Survey. Conducted for the Commission on Gender Equality. South Africa. 8. South African Demographic and Health Survey 2998. Department of Health, Medical Research Council and MACR. Preliminary report. 9. South African Demographic and Health Survey 2998. Department of Health, Medical Research Council and MACR. (In press) 10. Braam T (ed), 1998. Barometer Z(2). Reproductive Rights Alliance, Johannesburg. 11. Rispel L, Price M, Cabral J et al, 1996. ConfrontingNeed and Affordability: Guidelines for Primary Health Care Services in South Africa. Centre for Health
Policy, Department of Community Health, University
of Witwatersrand,
South Africa. ET, Lurie M et al. Barriers to implementing South Africa’s Termination of Pregnancy Act: A case study from rural KwaZulu/Natal province. Centre for Epidemiological Research in South Africa (CERSAYHlabisa, Medical Research Council, South Africa. (Draft) 13 Engelbrecht M, Pelser A, Ngwenya C et al, 1999. A Project 12 Harrison A, Montgomery
Management Strategy to Overcome Impediments to the Operation of the Choice on Termination ofpregnancy Act of 1996 in the Free State: Findings from the Survey. Centre for
Health Systems Research and Development, University of the Orange Free State, South Africa. 14. Fonn S, Xaba M, Tint KS et al,
Reproductive
1998.Transforming Reproductive Health Services: Results from a Multi-Faceted Research and Implementation Process from Three South African Provinces. Women’s Health Project, Johannesburg. 15 Details of the methodology are available from the Women’s Health Project on request. 16. Dawson S, Manderson L, Tallo V, 1992. The Focus Group Manual. Methods for Social Research in Tropical Diseases.
Health Matters, Vol. 8, No. 16, November 2000
No 1. UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases. Geneva. 17. Fonn S, Xaba M. 1995. Health Workers for Change: A Manual to Improve Quality of Care. Women’s Health Project, South Africa and UNDP/World Bank/WHO. Geneva. 18. Washington 00, Laisser R, Mbilima M et al. The impact of Health Workers for Change in seven settings: a useful
management and health system development tool. Health Policy and Planning. (In press) 19. Very few men take up nursing as a profession in South Africa. This 1O:l sex ratio reflects the sex ratio in both nursing and administrative jobs in the province. 20. The published interventions will be available in early 2001 from the Women’s Health Project.
R&sum6
Resumh
Afin que la loi sur l’avortement
Para que la ley de abort0 en Sudafrica se traduzca en servicios que aseguren la equidad de acceso y el derecho de la mujer de controlar su cuerpo, se precisan intervenciones dirigidas a cambiar las attitudes negativas hacia el aborto. Este trabajo describe una investigacidn formativa realizada en la Provincia de1 Cabo Norte, en la cual participaron 436 integrantes de la comunidad, 29 mujeres que querian abortar, y 80 proveedores de servicios de la salud. En base a 10s resultados, se efectuaron dos intervenciones, las cuales parecian tener bastante influencia sobre las attitudes de las personas al lograr que ellas vincularan la necesidad de servicios de abort0 con las circunstancias en que ocurren 10s embarazos no planificados. Entre las mujeres de la comunidad, hubo mayor apoyo para el derecho de la mujer de optar a abortar, pero no asi entre 10s hombres, quienes se opusieron a este derecho para las mujeres casadas. Entre 10s proveedores (casi todas mujeres), aumentd su disposition a favor de apoyar tanto la provision de servicios coma el personal que trabaja en dichos servicios. Estas herramientas podrian usarse en la education sexual escolar y en la capacitation de medicos y parteras profesionales, corn0 complement0 a las iniciativas politicas y programaticas en curso en Sudafrica, para ayudar a reducir el problema de salud publica que es el abort0 practicado en condiciones de riesgo.
en Afrique du Sud se traduise en services assurant l’egalite d’accbs et le droit des femmes a maitriser leur corps, il est necessaire de modifier les opinions negatives sur l’avortement. L’article decrit la recherche formative me&e dans la province du Cap-Nord parmi 436 membres de la communaute, 29 femmes souhaitant avorter et 80 praticiens de soins de Sante, pour elaborer des interventions approprices. Deux interventions ont ete mises au point en fonction des conclusions et elles ont influence sensiblement les opinions personnelles en incitant les gens a mettre en rapport la necessite de services d’avortement et les circonstances dans lesquelles les grossesses non d&i&es se produisent. Dans la communaute, on a note que les femmes appuyaient davantage le droit des femmes a avoir le choix en mat&-e d’avortement, contrairement aux hommes, qui refutent ce droit pour les femmes mariees. Les praticiens (des femmes pour la plupart) etaient plus desireux de soutenir la prestation de services et seconder le personnel travaillant dans les services d’avortement. Ces outils pourraient &tre utilises dans l’education sexuelle en milieu scolaire et dans la formation des medecins et infirmieresksages femmes pour completer les initiatives de plaidoyer mises en ceuvre actuellement aux niveaux des politiques et des programmes en Afrique du Sud, en vue de reduire le probleme de Sante publique pose par les avortements non medicalises.
111