Conscientious objectors who refuse to perform abortions or related services for moral reasons may have become a law unto themselves.
When Zinhle’s mother first found out that her 18-year-old daughter was three months pregnant, she was furious. Her anger quickly turned to anxiety as she tried to imagine how she’d support her daughter and a new baby on a part-time domestic worker’s salary. In her desperation, she decided that the best thing for everyone would be for Zinhle to have an abortion as soon as possible.
Without getting her daughter’s consent or telling her what she planned to do, she paid for Zinhle to travel to Durban under the pretext of helping her apply for an identity document.
When Zinhle arrived at her mother’s house, she was immediately taken to a private doctor and informed that the doctor was going to “put some pills into her vagina” to stop the pregnancy.
Zinhle was helpless, far from home and dependent on her mother, so she allowed the doctor to proceed. Within a few hours of the tablets being administered, she began to feel painful cramps in her lower abdomen and started bleeding from her vagina. She spent the night in Durban but had to return to her home village the next day.
Back home, she eventually expelled the foetus but the pain and bleeding worsened. Over the next few days, Zinhle developed an abnormal vaginal discharge and couldn’t walk because of the pain.
Realising that Zinhle was unwell, one of her relatives called an ambulance to take her to the nearest hospital, where she was diagnosed with a septic incomplete miscarriage and transferred to a regional hospital.
On arrival, Zinhle was taken to the operating theatre for an emergency evacuation of her uterus to remove the infected remains of her abortion and prevent the sepsis from spreading further.
The procedure was uncomplicated and lasted about 10 minutes. It involved inserting a tube connected to a vacuum through her cervix and sucking out the contents of her uterus.
Afterwards, Zinhle was admitted to the ward to start intravenous antibiotics and receive a blood transfusion, as she had lost a substantial amount of blood over the previous few days and was now severely anaemic.
This should have been the end of Zinhle’s woes. She should have recovered in the ward, been counselled about the use of contraception, had a session with the social worker and psychologist before leaving, and hopefully could have looked forward to a planned pregnancy in the future.
But her condition deteriorated and after five days she was rushed back to the operating theatre, this time for a hysterectomy – an emergency operation to remove her womb.
After the operation, Zinhle spent the next few days in the intensive care unit, receiving stronger antibiotics and medication to keep her heart rate and blood pressure stable.
Zinhle is lucky to be alive but the tragedy is that she’ll never have another pregnancy because she doesn’t have a womb.
She may be too young to comprehend the full significance of it now but in time being unable to bear her own children may turn out to be a terrible fate, given the social stigma many women who cannot conceive continue to face.
This year marks the 20-year anniversary of South Africa’s Choice on Termination of Pregnancy Act, which legalised abortion in the country. The Act was amended in 2008 to expand access to abortion services by removing some of the administrative constraints.
Two decades after the Act was passed, a gap remains between the legally enshrined rights of women and their actual access to legal and safe abortion services at public hospitals in South Africa.
The supply and demand of unsafe, illegal abortions thrives on this divide, mostly through brazen advertising in which no counternarrative exists to inform women that abortion is legal and can be done safely in most public hospitals.
Even when women know enough about their rights to demand these services, conscientious objectors obstructing access within public facilities would still be a problem.
Objectors can occur at all levels of the public health service, from denying a prescription to refusing to dispense or administer the tablets. Support services such as an ultrasound scan, which is needed to determine the gestational age of the pregnancy before proceeding with a termination, may be denied if the person doing the scan objects on religious or moral grounds. In this way, an entire service comes to a standstill.
Conscientious objection is an individual choice but in communities of predominantly closed social networks, it is often the result of societal and peer-group pressure or a top-down instruction from a senior figure.
White Christian missionaries have a long and what has been described as a “strangely ambiguous” history in rural South Africa. Since they arrived, they have purported to serve humanity while dictating a self-righteous moral code that perceived the local customs of indigenous people in an extremely biased way.
Polygamy, sex before marriage, sexual behaviour that deviated from traditional models of heterosexual relations and, of course, abortion were all condemned.
Fast forward to 2016 and there are still many rural communities dependent on former missionary hospitals for everything related to health. In these situations, a conscientious objector in a leadership position – with buy-in from community leaders – can severely undermine women’s constitutional right to reproductive health services.
This, in turn, drives abortion services – and women seeking them – underground and into precarious positions.
Although freedom of conscience is not covered in the Act, healthcare workers refer to the Bill of Rights to invoke their constitutional right to object.
The amended Act, however, is very clear about the consequences of obstructing access to a lawful request for an abortion. It warns that offenders will be “guilty of an offence and liable on conviction to a fine or to imprisonment for a period not exceeding 10 years”.
In a 2010 article, David McQuoid-Mason from the University of KwaZulu-Natal’s Centre for Socio-Legal Studies explains that, in an emergency situation, a doctor may only refuse to participate in a termination of pregnancy if there is another doctor available to do the procedure. In nonemergency situations, in keeping with the World Medical Assembly’s policy position, doctors who are unwilling to perform an abortion must refer the patient to a doctor who is prepared to do so.
McQuoid-Mason goes on to say that a failure to do so on conscientious grounds may be interpreted as imposing one’s religious beliefs on patients, which contravenes the physician’s oath.
I would add that this also goes against South Africa’s Batho Pele principles that seek to put people first in service delivery and guarantee access to, and information about, government services.
There’s a difference between participating in abortion procedures and other aspects of abortion provision. The right to conscientious objection only covers the former.
Healthcare workers who refuse to prescribe abortion medication, perform ultrasound scans, give pain medication or inform women of their rights before directing them to other service providers have it wrong.
In our less-than-ideal world, there will always be some level of secrecy and shame associated with having an abortion, no matter what the reason. Public sector healthcare workers who are left to manage the consequences of illegal and unsafe abortions must talk more about the nature and boundaries of conscientious objection, especially where it obstructs a legitimate service.
It doesn’t seem fair that doctors and nurses in positions of relative power and privilege compared with their patients are allowed to protect their own consciences and turn a blind eye to their indirect role in pushing vulnerable girls and women into the hands of illegal providers.
This is especially true in South Africa, where patriarchal values fuel what the United Nations describes as “pervasive” gender-based violence towards women.
There’s no doubt that access to legal and safe pregnancy termination has reduced the number of pregnant women dying because of septic abortions. But with 114 deaths being reported from septic miscarriage between 2011 and 2013, it’s still the fifth-biggest direct underlying cause of maternal death in South Africa, according to the most recent government report on the causes of maternal deaths.
The need to promote access to contraception and to engage communities in reducing maternal deaths is given extensive attention in the report. Sadly, no mention is made of the need to deal with the issue of conscientious objection or to provide information and promote access to safe and legal termination of pregnancy at health facilities.
In this regard, the institutional silence on the matter is deafening.
Perhaps if we counted the number of girls and women who lose their wombs to life-saving hysterectomies or who suffer other organ damage just short of death because of botched abortions, it would reveal a situation worth speaking out about.
Until then, people like Zinhle will remain in the shadow of their trauma, robbed of their chance to have their own children, and the rest of us will go on as if it’s not our problem.
Indira Govender is a rural doctor in KwaZulu-Natal and a member of the Rural Doctors Association of Southern Africa. She writes in her personal capacity. Follow her on Twitter @indigoesround.