Abstract
South Africa legalised abortion in 1996. I am originally from the Netherlands and came to South Africa in 2000, to assist in the Termination of Pregnancy programme. In March 2007, at an international conference on second trimester abortion, I described my life as an abortion doctor living in Cape Town, South Africa. I was urged to write down what my working life in the Western Cape is like, and this paper is the result. It is a diary of a typical work week, recorded in early 2008.
Résumé
L'Afrique du Sud a légalisé l'avortement en 1996. Originaire des Pays-Bas, je suis arrivée en Afrique du Sud en 2000, pour aider le programme d'interruption de grossesse. En mars 2007, au cours d'une conférence internationale sur l'avortement du deuxième trimestre, j'ai évoqué ma vie en tant que médecin pratiquant des avortements au Cap, en Afrique du Sud. On m'a demandé de décrire ma vie professionnelle dans la province du Cap-Occidental, ce que j'ai fait dans le présent article. C'est le journal d'une semaine ordinaire, début 2008.
Resumen
En Sudáfrica se legalizó el aborto en 1996. Yo soy de origen holandés y vine a Sudáfrica en el año 2000, para ayudar con el programa de Interrupción del Embarazo. En marzo de 2007, en una conferencia internacional sobre el aborto en el segundo trimestre, describí mi vida como médico abortista que vive en Ciudad del Cabo, Sudáfrica. Me instaron a escribir sobre mi vida laboral en el Cabo Occidental, y este artículo es el resultado. Es un diario de una semana típica de trabajo, documentada a principios de 2008.
This is my “busy” week. Every second week, I travel in and around Cape Town to different facilities and perform second trimester abortions, often at two sites a day. My other week is usually a quieter week, which often means writing articles, giving lectures, going to meetings and so on. I am one of three roving team doctors in Cape Town, but at the moment there are only two of us. Our other colleague had a car accident at the end of November and is not yet back at work. I have taken over most of her lists and, especially before Christmas, it is a very heavy workload.
Monday
The week starts not too bad. I only work at the Marie Stopes clinic in one of the suburbs and perform eight second trimester terminations. No problems, apart from the fact that the electricity is not working, but I have enough light coming through the windows. The only problem is that I can't do a scan and the fan is not working. Later in the afternoon, I have my (almost) weekly massage. I have convinced myself that I need (and deserve) this, and I am really enjoying it.
Tuesday morning
My morning starts with taking part in the “After Eight Debate”, a popular radio programme on South Africa FM. This morning it is dealing with abortion, and they called me yesterday afternoon to ask if I wanted to be part of the panel. I agreed, although later, after discussing this with other members of the Reproductive Rights Alliance, I try to argue that we want one of our “black” members to take part in the discussion. In South Africa, people are still not “colour-blind” and as a “white” person (which people can hear from my accent), I might be accused of wanting to force these (abortions) on the black population. Arguments such as “This is not part of our culture” are often heard. However, South Africa FM does not want to make any changes at this stage. So I am on.
I'm lucky, we are three panel members, and only one is from Doctors for Life, the other is the chairperson of the Portfolio Commission on Health who defended the Choice on Termination of Pregnancy Amendment Bill in Parliament last week (and the Bill was passed, at last!). This Amendment Bill is especially meant to improve the accessibility of abortion services; for instance, instead of only nurse-midwives, registered nurses are now also allowed, after training, to perform first trimester procedures. Several people call in, both pro-choice and anti-choice. But in the end I still feel a bit frustrated, because I haven't really been able to say all I wanted to say. However, I get lots of SMS text messages saying that I did OK, so that helps.
After this ordeal I go to one of the township hospitals and do the ultrasound scans, quick, and in about an hour I am finished. This hospital functions as an “overflow” unit for the region, so we see many women with unwanted pregnancies here, needing both first and second trimester abortions. On Monday mornings, another doctor does the scans and I come on the Tuesdays and do scans for another ± 40 women. We just want to know how far pregnant they are. The ones needing first trimester are booked for the nurses. They do it themselves with manual vacuum aspiration (MVA) up to 12 weeks. The second trimesters (13–20 weeks) are booked for the other doctor and I, each doing one day. I don't normally perform abortions anymore in this hospital, but since my colleague's car accident, I have to do her list since there is no one else prepared to do it. One of the nurses makes the bookings. I emphasise that I don't want to do more than 20 cases in a day. Although I really find 20 too much, I am more or less forced to do that many. My other colleague, Dr S, is willing to do 30 a day, and I have to do the rest. We all know these numbers are too high and that's why Dr S lets the women start with the misoprostol (they take it sub-lingually) already at around 10pm the evening before, even though the misoprostol was originally only meant for priming of the cervix. My list of women are asked to start the misoprostol at three o'clock in the morning, which is still a bit early and quite inconvenient for them, I think.
I am of the opinion that it is irresponsible to let women start the evening before with taking the misoprostol. Several of the women abort at home as a result or at least they start bleeding. Many abort once they arrive early in the morning at casualty, so Dr S can then just do a standard suction. At least half of her patients have aborted by morning, although she is supposed to be doing the so-called surgical abortions!
I could complain about this, but since we have no other doctors willing to do the second trimesters, we are just letting her do it her way.
Wednesday
This is my George day, which I do once in two weeks. I am very happy that I am now able to fly to George instead of driving, something I have done for almost six years (it's 425 km one way!). I perform the second trimesters here at the Marie Stopes clinic: the whole region can send their patients here for free, since Marie Stopes has a contract with the regional Department of Health in this region. There are 13 women, two have not arrived. Some come from really very far away, but they were lucky today because they could make use of the state ambulance, but they had to leave home about 3:30am! This “after the holidays” period is notorious for the high number of women needing a termination and for the many second trimesters. I have four women today who are 19 weeks pregnant and one is 20 weeks. I am very happy that they are all well-dilated. That is always my fear, as the misoprostol does not always work that well. Sometimes I am really struggling and the problem is time. I have to finish the procedures now. I examine the women when I arrive and the ones not dilated enough I give another dose of misoprostol vaginally and help them last. Usually I have no problem and I am finished early, which means I can wait for my plane back home at the airport restaurant and work on my laptop. The airport has wireless. But today, I have just finished in time. I arrive at the airport 20 minutes before the plane is leaving. It is only a 50-minute flight, and I am home around 7pm.
In the evening, I visit my colleague who had the car accident. She is much better and will probably start working again soon, although she will start half-time. But that will relieve me a lot already. I discuss with her what happened to me last Friday, at the Marie Stopes clinic in town. It is really necessary to be able to air my frustrations, in fact we both do that regularly. Performing terminations of pregnancy and especially doing second trimesters, is a lonely struggle. The nurses usually don't understand our problems very well. If I have a complication, such as a perforation, I'll have to send the woman to the nearest hospital. But some of these colleagues don't have much understanding; instead they consider it as “my problem” and they curse me for doing these abortions.
I have been very lucky, though, I haven't had a serious complication for the last four years. However, last week I did have a complication in the Marie Stopes clinic in Cape Town. It happened with an 18-year-old girl, she was 18 weeks pregnant and she had opted for conscious sedation (this is not possible in state facilities). This clinic is normally the job of my still out-of-kilter colleague and I have agreed for this period to do the second trimester terminations there. Women pay extra for conscious sedation, which is given by another doctor. This 18-year-old girl was now very anxious, but because she was on the conscious sedation medication it did not help to ask her to lie still. She was constantly moving up and down, screaming, so one nurse had to hold her one leg, another the other leg, to try to keep her still. On top of this, the cervix was not well-dilated and after struggling for a while and not getting much fetal material, I saw fat, which means omentum (part of the peritoneum). I really felt bad, it was clear that I had made a perforation. We tried to get her admitted, first, to the very nearby private hospital. However, they wanted to see money first. So we decided to get her to the nearest state hospital in an ambulance. Miraculously, getting her there all went quite quickly (though it isn't normally so easy). In the evening, I called the hospital to find out what they had done for her, but they said they'd done nothing yet!! The next day I heard they had operated on her only at 10pm that night (the perforation had happened at 2pm) and that she had lost quite a large amount of blood. I was very relieved to hear that no other internal organs had been damaged and that they could close the tear in the uterus. In the evening I called the girl's mother and explained to her what had happened (luckily the mother knew about the abortion). Although the Marie Stopes nurse had spoken to the mother before, she apparently did not understand very well what had happened. She was happy with my explanation, but still wanted the money back from Marie Stopes. This is of course not my business, but I feel that it is not right to give money back, because that gives the impression that it is we who have made a mistake. Women sign before the procedure that they have been told that there are certain risks involved, although the chance is very small.
Thursday, a busy day
I start at 8am in a hospital in one of the suburbs, and there are only seven women for me. They don't want to book more, because I have to work in the “small theatre” and they need this theatre for other procedures too (which they find more important than abortions). In December I had a fight with them about this, because they had women on a waiting list for at least three weeks and because of this many were pushed into the second trimester. I only started in December at this hospital, I took over from my colleague, Dr S, who did not want to go there anymore. The first day I worked there I noticed that all the women had been on the waiting list for three weeks already, and as a result one was 20 weeks pregnant on the day I saw her. Yet when she came for the ultrasound she was “only” 17 weeks. The others were in the first trimester when the ultrasound was done, but because of the delay they were now also second trimesters. I was furious and had a telephonic discussion with the people responsible. I succeeded in having the nurse do extra sessions with the first trimesters, so we were able to work away the backlog before Christmas. And from now on, I will be watching carefully what the booking clerk does, so that no new waiting list is created.
After a quick cup of coffee, I drive to W at around 11am, 115 km from Cape Town. I arrive at 12:30pm and there are ten women waiting for me on the hard wooden benches, in a very cramped waiting area. We have to work in a temporary space in this hospital, and my procedure room is really tiny!! I think it measures barely 2.4×2.5m. Apart from myself and the woman, there are two nurses in the room. Luckily, we have had air conditioning for the past two months. Last year at around this time, I nearly suffocated. (This is a very hot place in summer!) They have been doing building work on the hospital for at least four years already, and they keep on promising that our new procedure room will soon be finished.
The women start with the sublingual misoprostol when they arrive at the hospital. I ask them to come between 7 and 8am, so when I arrive I start with the ones that have arrived first. However, some have come really late today, transport is often a problem for them.
There are four young girls today, one is 16 years old, two are 17 years old and one is 18 years. W is in the middle of the Western Cape wine farming area. We see a lot of teenage pregnancies here, and fetal alcohol syndrome is still very common as well. In the apartheid years, the farmers used to pay there labourers partly in alcohol, the so-called dop (a tot in English) system, which is forbidden now, but it probably still happens. Many of the labourers are seasonal nowadays.
I am finished around 3:30pm. Driving back home I get stuck in traffic. In the evening, I see that I've received an e-mail from Ipas, in which they confirm my participation in doing a second trimester training of one week. I can't believe that they have succeeded in finding 15 doctors willing to be trained! I don't know what is wrong with the Western Cape. All these doctors, except one, are coming from the other provinces for this training; we in this province haven't been able to find more than one doctor to participate. But we will do the training here in Cape Town; because of our system with the roving team, we have a much higher number of second trimesters “available” for training. I'm very excited that we will be able to go ahead with this training.
Friday, a really busy day!
I first have to go to A, a small town, desolate and sandy, ± 65 km north of Cape Town. I usually do first and second trimesters here and I am expecting many patients, because two weeks ago I was supposed to do some of the ones I have today, but they had cancelled all the terminations. Their counsellor hadn't come back yet, and nobody else in the hospital wanted to counsel the abortion patients, so the 20 (!!) women who were waiting had to be sent away. So I am very surprised and suspicious to see only 13 women today. When I ask the nurse how this is possible, she is also upset and says that there is a new doctor doing the scans and she is showing the images to the women and telling them that they are murderers. Two weeks ago, she had personally referred ten of the women with more advanced pregnancies to one of the hospitals in Cape Town, but she did not know if they had ever gone. The problem for most of these women is that this other hospital wants to do the counselling first on one day and the abortions on another day, which means the women have to go twice. Many can't afford the transport. A is known for its high unemployment figures.
So I only have four early second trimesters, the others are first trimesters. It means I am finished rather early. As usual I eat my lunch while driving to my second site for the day, the township hospital, where I did the scans on Tuesday. When I arrive, a whole group of women are already sitting and waiting on plastic chairs, with linen “towels” between their legs (actually linen savers, not towels, they are disposable sheets of paper and plastic), because several have started bleeding already. There are 18 second trimester patients, which I already knew because I had called the hospital to find out how many they had booked for me.
I was curious to know what had happened after I received a phone call, the day before, Thursday, early in the morning, from one of the nurses. She was very upset, because 50 second trimester patients had arrived for that day. Apparently one of the referral clinics had not consulted her about which day they could send their patients, they had just told them to come on Thursday. Of course it was impossible for my colleague to do 50 second trimesters, but the problem was that the women had already started at 10pm the night before with the misoprostol. So I advised the nurse to observe them all, and with the ones that had not started bleeding or had not aborted yet, to send them home and let them come back the next day.
So most of the 18 women I was seeing today were here for the second time. They had received another two misoprostol tablets in the morning, and some were bleeding and a few had even aborted by now. However, most of the women did not react so favourably to the misoprostol. They were not very well dilated and even the three who were 19 weeks and the one who was 20 weeks were not easy to dilate. I really struggled that afternoon and I was only finished at 6pm and totally exhausted.
Saturday
Once every fortnight, I do the terminations at Mosaic, an NGO which functions as a training, service and healing centre for women. We started a Comprehensive Reproductive Health clinic in their building a few years ago, but because of lack of funding we can only employ one reproductive health nurse, who does the MVAs during the week. A colleague of mine and I alternate to do the procedures on the Saturday mornings. Usually there are ±15 patients, mostly first trimesters. Quite a number of them are students from the University of Cape Town. Also this morning, my first patient is a final-year medical student. During the procedure I have a discussion with her about abortion and the activities of Students for Life. She is not very clear about where she stands, but she admits that Students for Life are very active among the medical students. I have noticed that, when I give my “abortion” lecture to the sixth-year medical students. Usually about half of them have a very negative attitude.
This morning at Mosaic becomes very special. As I enter the procedure room the electricity goes off. South Africa is battling with its growing energy supply needs, and there is clearly not enough electricity available anymore. For two weeks already now, they are “load shedding”, that is, for 2–3 hours in different areas the electricity is turned off. Businesses selling generators are doing very well! Hospitals also have generators. But not Mosaic. And since there are no windows in the procedure room it is pitch dark. We have one torch, so we use that to provide light for me to shine into the vagina, and the rest of the room is lit by candles. We make jokes with the women and tell them that they are getting very special treatment – abortion by candlelight!
Three hours later, when I am finished at last, the power is still off. The nurse and I had both almost fainted because it got so stuffy and hot inside the room.
At last, my weekend can start, and I plan to have a good rest. However, when I arrive home and see the weekend newspaper, I know that at some stage today or on Sunday I must sit down at my laptop and react to the sensationalist and horrible story about abortion in the newspaper.
On the front page the story is already advertised, there are little coffins and a text about “killing babies”. The actual article consists of two interviews with women who had recently had an abortion. The one had been in a state facility, the other at a private clinic. The headline especially put me off: “They were cutting up the fetus and threw the pieces into a dish” and the woman says she could hear the fetus being crushed! The other interview starts with “I was capable of killing my baby”. Both women state at the end that they had made the right decision in having an abortion. But apparently they were both appalled at the way the abortion was done. To me, it looked as if they didn't realise they were going to feel something, they had just wanted to be sedated and wake up and find that “it” was gone. And both had had extreme cramps from the misoprostol for the priming of the cervix.
Although it was a very sensationalist article, it did make clear to me how important it is to give the right information to women ánd to offer verbal “sedation” during the abortion procedure. I did write a letter to the editor and had contact with the journalist. I explained in the letter how abortions are done, medical and surgical, that abortion especially in the first trimester is a very safe and simple procedure and that it is therefore preferable to come as early in the pregnancy as possible. A termination of pregnancy in the second trimester is a more complicated procedure and the risk of complications increases with the length of pregnancy. A week later, in the next weekend's edition, they published my letter, giving it a lot of space and with a big headline: “Key pointers on abortion”.
At last I can stop and rest! It is a comforting thought that my colleague will be partly back to work next week, so the pressure will be less. But life is full of surprises: in the eight years I have worked here in the Western Cape, there has never been a dull moment!!