Strengthening Referrals: Step One to addressing the challenges of Conscientious Objection in abortion services

The death of Savita Halappanavar, who died of septic shock after being denied an abortion in 2012 in Ireland, catalysed the movement to repeal the Eighth Amendment of the Irish Constitution — that banned abortion under almost all circumstances – in a landslide victory for the “yes” vote in the referendum.

As a doctor, I have treated many women suffering from complications due to botched abortions from backstreet abortion providers. The consequences of unsafe abortions can be dire. Many women have come to me with septic shock, multi-organ failure, infected reproductive organs or a uterus with no blood supply to keep it healthy and salvageable. These women need to be resuscitated, stabilised and some need surgery to remove their uterus in order to save their lives. Some women, sadly, lose their lives.

Provision of safe and legal abortion services is a crucial aspect of ensuring women’s reproductive health and is essential to safeguarding their rights and well-being. Our landmark Choice on Termination of Pregnancy Act (CTOPA) of 1996, one of the most progressive abortion laws in the world, extended the freedom of choice to every South African woman by giving her the right to terminate an unwanted pregnancy on request up to twelve weeks. However, 22 years on, many women still struggle to access safe and legal services in South Africa. Complications I mentioned above could have been prevented if access to safe abortion services were available to all women who needed them.

While we have made strides in increasing access to safe abortion services, several systemic, policy, socio-economic and cultural barriers prevent the CTOPA from being fully implemented. According to the WHO (World Health Organisation), conscientious objection by health care providers without referrals is one of the major barriers to accessing safe abortion services. It is a reality for many women seeking abortion services in public facilities in South Africa.

While CTOPA does not directly address conscientious objection, the practice is understood to stem from the right to freedom of conscience, enshrined in the South African Constitution. Health care providers often refuse to provide abortion services on moral or religious grounds, despite abortions being legal. Additionally, many stigmatise other willing providers, who out of fear of backlash or ostracisation also refrain from providing services.

Conscientious objectors should refer the woman to another willing service provider or health facility. However, this hardly happens, compelling women to seek “backstreet” abortions from providers, who often lure women in the name of providing “privacy” and “immediacy of services”. As doctors, we find ourselves racing against time to manage health complications in women resulting from unsafe abortions.

Given the significant challenge that conscientious objection poses to women’s health and lives, there is an urgent need to strengthen the referral system at health care facilities. This is key to increasing access, preventing women from seeking unsafe abortions, and reducing maternal mortality and morbidity in South Africa.

Due to a lack of clear abortion guidelines for health care providers, conscientious objection has remained largely unregulated and often applied in an ad hoc manner, leading to this shortage of health facilities offering abortion services. According to a report by Amnesty International, only 264 of the 505 designated South African public health facilities provide abortion services. In the operational facilities, the bulk of the work falls on a skeleton staff that often buckles under the pressure.

The government, therefore, has a critical role to play. It should actively map abortion service delivery failures due to conscientious objection in the designated public health facilities and institute an effective referral system in each designated centre, so that women are not denied services. Currently this does not exist. Deliberations around the 2007 Draft National Policy for Conscientious Objection need to restart. If this policy comes to fruition, it could go a long way in regulating conscientious objection and improving service delivery across the country.

As providers, we have a role to play too. We took the Hippocratic Oath to save lives. Denying a woman an abortion without referrals and compelling her to use unsafe means to terminate a pregnancy goes against this very oath. We must remember that we are obligated to provide abortion care in emergency conditions even if we are conscientious objectors and must be aware of the circumstances under which conscientious objection can or cannot be applied. We should also inform the hospital/clinic management of our decision to conscientiously object at the very outset so that the management can ensure the availability of other trained and willing abortion providers.

The CTOPA is one of the most progressive abortion laws in the world. Women should not have to struggle to access these services. As we celebrate Ireland’s victory in taking action for its women, here in South Africa, we all must play our part in ensuring that women have access to life-saving services – such as abortion, in a timely manner and without facing any challenges or prejudice. DM

Dr Ntandho Godi is the Chief Specialist and Head of Department Obstetrics and Gynaecologists at Rob Ferreira hospital in Nelspruit, Mpumalanga. He is also Lead Doctor for Global Doctors for Choice South Africa (GDC-SA) - an organisation involved in advocacy for reproductive health and rights in the country.