1. Introduction and Background

The National Progressive Primary Health Care Network (NPPHCN) is a national non-government organisation founded in 1987 to advocate for the implementation of a national health system for South Africa based on the principles of the Primary Health Care (PHC) approach. NPPHCN has a membership of more than 1,100 health and development programmes, projects and individuals. We have offices in eight of the nine provinces and our national office is based in Johannesburg.

As the majority of members are women, living in disadvantaged communities, NPPHCN has a vital interest in this legislation. NPPHCN believes that backstreet abortions in South Africa are a major public health and development problem. We, therefore, support this legislation which will allow greater access to termination of pregnancy service under safe conditions for South African women.

NPPHCN believes that the Termination of Pregnancy Bill should not be viewed in isolation. Rather it should viewed in the broader context of providing comprehensive reproductive health services to women. The proposed bill should increase the choices available to women in relation to their own bodies and therefore increase control over their own lives. These changes are in line with the principles of our new democracy.

Although our position has the full endorsement of the National Executive Committee (NEC), the highest decision making body in the organisation, NPPHCN does not imply that it is presenting a homogenous, or monolithic position. We acknowledge that this is a very complex issue and that some of our member projects and individuals may have different opinions than those stated here. NPPHCN respects all people's choices. To us, the Termination of Pregnancy Bill is fundamentally about respecting women's ability to choose for themselves and providing the space for others not to have terminations.

2. The Constitutional Context

The Constitution must serve as the benchmark to measure all legislation. In our view, this Bill is clearly in line with the Constitution. Section 12 (2) of the Bill of Rights recognises the rights of women to make choice about their reproductive health. "Everybody has the right to bodily and psychological integrity, which includes the right :

1. to make decisions concerning reproduction; and
2. to security in and control over their body"

Further, women have the right to life, human dignity, freedom and security enshrined in the Constitution. The combination of these fundamental human rights guarantee women control over their bodies and reproductive decisions.

It is recognised that the state has an obligation to protect the sanctity of human life and not to legislate morality. We believe that the progressive limitations on the rights of women to abort as the foetus ages in the Termination of Pregnancy Bill satisfy the state's obligation in this regard.

3. NPPHCN's Positions

NPPHCN has identified several critical issues in this debate that will essentially determine whether this bill will be a hollow document or will positively impact on the lives of women.

Deaths due to back street abortions are real. Until there is a safe, accessible, affordable alternative, women will continue to choose this option and endanger their lives.

In order for this Bill to truly empower women, it must allow them freedom to choose for themselves. Requiring women to receive the consent of their partners or their parents before terminating their pregnancy effectively places barriers in front of them and compromises their rights to choose.

3.1. Death due to backstreet abortion

The present Abortion and Sterilisation Act, 1975 allows women to procure an abortion under certain conditions. However, not many people know this fact. In a 1994 MRC study, women were interviewed who presented at hospitals due to miscarriages or incomplete abortions. This study lists reasons why women procure illegal abortions, often done under non-sterile and unsafe conditions, and the methods women employ to induce an abortion.

The study also provides an estimate of the number of women (465) who die because of backstreet abortions each year in South Africa. The authors of the study state that the figure is based on reported cases, and therefore could be an underestimate of the actual situation in the country. Many women have successful backstreet abortions at the time but may present at a later date with problems.

NPPHCN has been holding discussion groups with women in different provinces. In one group discussion in Gauteng, 5 women out of 20 collectively knew of 7 cases of death due to backstreet abortion - women who were close friends, relatives and neighbours. This real and tragic phenomenon needs to be addressed urgently.

3.2 Minors and parental consent

The NPPHCN believes that if minors are required to seek the consent of their parents, it will have a negative impact in terms of her choice to abort, the young girl's life, and her relationship with her family.

It is estimated that 400 out of every 1000 live births are to girls under 19 years old. Different studies have shown that young people often become sexually active despite not having adequate information about their bodies, sex, and reproduction. This situation often results from a lack of communication between parents and children, and the absence of sexuality and life skills education in the formal school curriculum.

In a study by Flisher, young girls reported that their first sexual experience were often forced or were unplanned. In addition to this, numerous studies have found that young people have problems in accessing contraceptive services. It is often the combination of these factors that lead to young girls becoming pregnant.

In a 1995 NPPHCN study, young people repeatedly highlighted that they have very poor family communication especially around sexual issues. Below are some comments from young people from the study:

communication with parents

"I was not brought up in family in which I was given the privilege of voicing my problems with my parents or discussing issues related to our health as young people ... I would like to discuss my problems ... my future ... with my mother ..." Gauteng, Informal settlement, African, female, 17 -20

"Parents don't want to discuss or talk about sex ... according to our culture that shows rudeness" .. Gauteng, informal settlement, African, male, 12 - 13

"I don't want my parents to know that I am sexually active ... they will beat me up. They think you are doing bad/wrong things" Gauteng, informal settlement, African, male, 12 - 13

methods mentioned by young people to induce abortion

"... they say sitting on top of a bottle and letting it penetrate to your womb will kill the baby ... some use a copper wire to hurt themselves in the womb and they bleed ... some put babies in plastic bags and throw them away ... " North West, village, African, female, 17 - 20

"... drink jik or sta soft ...eating a one cent coin ... ' peita'[anal suppository] with sunlight [ie. liquid soap]" North West, town, African, male, 12 -13

reasons for abortions

"... no father to support ... only thing she could do ... maybe she wants to continue her schooling..." KZN, township, Indian, female, 11 - 13

"females perform abortion because they don't have money to feed the child" KZN, township, African, female, 10 - 11

"if a girl is pregnant and does not want her parent to know ... she has an abortion" North West, town, African, male, 12 - 13

Restrictive laws will further inhibit young girls from seeking safe medical care for pregnancy, whether she chooses to continue the pregnancy or not. NPPHCN believes that the problems of lack of information, poor communication in families, absence of sexuality and life skills education and poor access to contraceptive services should be considered when deciding about the issue of parental consent. In addition to the problems listed here, young people experience many other difficulties in relation to sexuality. These factors will most likely result in many young girls continuing to seek back street abortions if the law insist on parental consent.

3.3 Partner consent

NPPHCN supports the recommendation proposed in the Termination of Pregnancy Bill, which states that only the consent of the women is needed to procure a termination.

In the face of many social and economic difficulties faced by women and the unequal power relationships that exist between men and women in society, we believe that the inclusion of the requirement of partner or spousal consent will restrict women's choices. In a 1994 study by the MRC, women listed the fact that they were not in stable relationships or that their relationships changed after their partner was informed of their pregnancy (male partners either denying responsibility or wanted women to choose between termination and continued relationship), as a major reason for seeking abortions.

It is estimated that 1 in 6 women live in abusive relationships. Some women may discuss their sexual health with their partners, but forcing women to procure the permission of their abusive partner may place her in grave danger. Additionally, a significant percentage (30%) of South African households are headed by single women, who have the responsibility for the social, physical, emotional and financial well-being of their families. These women should be granted the right to make her own reproductive choices.

3.4 Late presentation by pregnant women

The fact of life is that most South African women present for antenatal care after the first trimester (women only present to health services after 16 - 18 weeks of pregnancy) of their pregnancies effectively limiting their choices. The legislation as currently drafted will not offer most pregnant women a choice. Much more educational and outreach work is needed to help women present earlier in their pregnancies. This will improve chances for infant and maternal survival and also give women more choices about their pregnancy. The quality of service urgently needs to change to encourage earlier reporting.

4. Issues Requiring Further Clarity and Proposed Technical Amendments

Although NPPHCN generally supports the legislation as drafted, we believe that there are several aspects of the Bill where further clarity is needed and technical amendment should be made.

In order to give full effect to some provisions of the Bill, the following definitions should be included:

• the term counsellor should include community health workers and lay counsellors
• sexual abuse has been included under section 2 (1) b ii (bb) but has not been defined. This should be corrected in line with international definitions.

Under section 2(1)(a), it is not clear what would constitute a request as the text is currently drafted. Potentially, this could include verbal, telephonic, physical or written requests. Further clarity is needed here. Additionally, what record keeping and monitoring mechanisms will be put in place to see if requests are met? Without these mechanisms in place, it will be difficult to identify continuing barriers to abortion services after the legislation is implemented.

In section 2(1)(b), NPPHCN believes that only one medical opinion should be required. Currently, there is the need to consult with another medical practitioner. It is not clear what constructive purpose this requirement serves and it could become another barrier to access.

In both sections 2(2) and 7(1), incapable needs to be defined and under what conditions a woman would be considered incapable must be specified. We believe that this section should be rewritten to read ... "not able to ... because of physical or mental incapacity". The legislation should enshrine the language of empowerment.

In section 3, much discretion is given to the Minister of Health to designate facilities where abortions can take place. Although the current Minister supports this Act, it leaves women's access very vulnerable in the long-term. Some guidelines could be added to safeguard access for all women. For example, what mechanisms will be put in place to ensure accessibility to facilities? For example, will government subsidise poor women to ensure access to these services? Will government ensure that these services are available in rural areas?

In section 6, it is generally recognised that there are insufficient social workers to meet the potential demand created by this legislation. NPPHCN recommends that voluntary, non-directive counselling be provided by lay counsellors and community health workers in addition to properly trained social workers.

In section 8 describing mechanisms to monitor referrals it is not clear if transport and other costs will be subsidised by the government if women needs to travel outside of their area in order to have an abortion because these services are not available in her community. If some arrangements are not made, abortions will continue to be limited to white, affluent women.

5. NPPHCN's Implementation Recommendations

NPPHCN views the passage of legislation as one step in a much longer process to ensure women's choice. We believe that a massive public information and education campaign about reproductive health, including abortion and contraception is needed. This will facilitate the effective implementation of the bill. NPPHCN's research clearly indicates that people's views change when they are provided with more education. Further, it appears that some public opposition to the Bill is based on the wrong impression that it is encouraging or requiring abortion rather than providing women with a choice whether or not to have one. These misunderstandings would be clarified through a public education process.

There is also a clear need to introduce sexuality and life skills education into formal school curriculums. As evidenced from NPPHCN's research, young people do not have access to information or resources to enable them to make responsible and informed choices concerning sexuality. Integration of sexuality and life skills into the education will demystify human sexuality and begin to address the causes of unwanted pregnancy.

Sister Doreen Mfikoe, from the Northern Province, highlighted the appalling condition of reproductive health services in the country. The history of family planning in South Africa was inextricably interlinked with apartheid efforts to control the black population. Family planning is still not accepted in certain areas and therefore there is difficulty around the provision of these services.

Reproductive health should be viewed as an integral part of comprehensive primary health care services. Thus, the Department of Health should focus on provision to accessible reproductive health services, the retraining of health workers in terms of value clarification and understanding the difference between personal and medical ethics and morals, and subsidising access to reproductive health care eg. transport.

Based on the testimony presented at the three days of hearings, very little research has been done in the area of reproductive health and abortion. In particular, community based research has been severely neglected. NPPHCN believes that this research is essential to determine the need and problems of communities. We believe that this type of research should be initiated immediately and be ongoing.

Finally, women who have problems or experience difficulties accessing safe abortion services must have a mechanism to assist them. There are many potential options to achieve this aim. One option is to operate a toll-free, 0800 help line specifically for reproductive health issues. Alternatively, ombudspersons at health facilities or at the district level could serve this function. Whichever alternative is chosen, people serving in this capacity must be properly trained and sensitised to these issues.

Last updated: 24/05/00
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