‘I am all alone’: factors influencing the provision of termination of pregnancy services in two South African provinces

ABSTRACT

Background: Globally, universal access to sexual and reproductive health care services has been re-emphasised. One-third of maternal deaths could be averted by improving access to safe abortion services. Anecdotal evidence suggests that the implementation of the Choice of Termination of Pregnancy Act has been suboptimal in South Africa.

Objectives: In two South African provinces, determine: the proportion of designated termination of pregnancy (TOP) facilities that provide these services; explore the factors that influence the provision of TOP services; and explore the work experiences of health care providers at designated TOP facilities.

Methods: During 2014 and 2015, we conducted a cross-sectional study at designated TOP facilities in Gauteng and North West provinces. A combination of methods was used, consisting of: site visits to, and observation of, each of the designated facilities using a checklist, and in-depth interviews with a sub-set of 30 TOP service providers, using a semi-structured interview schedule. The interview questions focused on the factors influencing TOP service provision, and the work experiences of TOP service providers. We used interpretative phenomenological analysis to analyse the data from the interviews.

Results: Overall, 77% (47/61) of designated facilities were providing TOP services, with 87.5% (28/32) in Gauteng Province, compared with 65.5% (19/29) in North West Province. Service provision was influenced by health system deficiencies, human resource challenges, lack of prioritisation and lack of management support. Study participants reported a heavy burden of care provision and expressed an overwhelming feeling of loneliness, courtesy stigma and lack of support from other nurses and doctors, which further influence TOP service provision.

Conclusions: South Africa has an enabling legal environment for the provision of TOP services. Supportive management, prioritisation of TOP services and employee wellness programmes to address the psychosocial issues experienced by providers are critical elements of an enabling health policy environment.

KEYWORDS:

• Abortion
• termination of pregnancy
• health care provider
• South Africa

Responsible Editor Maria Emmelin, Lund University, Sweden

Responsible Editor Maria Emmelin, Lund University, Sweden

Acknowledgments

Dr Jessica Ruthven is thanked for her assistance with data analysis. We thank the managers in Gauteng and North West for study approval. The invaluable insights provided by the TOP service providers are acknowledged gratefully.

Disclosure statement

No potential conflict of interest was reported by the authors.

Ethics and consent

Obtained and included in the main body of the manuscript.

Paper context

Previous research on this topic has focused on access barriers to the provision of termination of pregnancy (TOP) services, and conscientious objection by health care providers. This paper adds new knowledge on the loneliness experienced by TOP health care providers, and their experiences of courtesy stigma from their colleagues and managers. We recommend prioritisation of TOP service provision, employee wellness programmes and supportive management to address the psychosocial issues experienced by these providers.

Additional information

Funding

Part of the study was funded by the Gender and Health Division of the School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.

Notes on contributors

Mantshi E. Teffo

Both MET and LCR designed and conceptualised the study. LCR is the PhD supervisor. MET and LCR analysed the data with input from a third researcher. Both authors contributed equally to the interpretation of study findings, and the writing, substantial revision and editing of the manuscript. Both authors read and approved the final draft of the manuscript.