The stark and honest descriptions of the challenges faced by healthcare professionals in South Africa when providing safe abortion care and postpartum family planning.
Judiac Ranape, a nurse from Lady Michaelis Community Day Centre in Western Cape, South Africa
I am the only nurse trained in safe abortion in the whole of my region and women seeking abortion must attend appointments on five different days.
I did a termination of pregnancy course five years ago and do first trimester medical and surgical abortions on a Monday and Wednesday. I am expected to see ‘critical illness’ patients on Tuesday, Thursday and Friday but I always squeeze in reproductive health patients that need me because medical abortions don’t only fall on a Monday and Wednesday.
I used to assist a roving team of Marie Stopes nurses, but in 2010 I officially started doing the procedures myself. It wasn’t easy as I felt it was against my religious beliefs. On some Sundays I couldn’t sleep because I was dreading Mondays but then I did a safe abortion course and completed the values clarification exercises and gained a better understanding of the importance of abortion care. It was difficult at first. I had to learn through the service and grow into it and adopt it and eventually feel comfortable with it.
Through time I’ve grown to be strong enough to say that there are people who need the service. Until someone steps into my shoes and listens to these women and sees what they look like when they come in they will not understand why I do this work. I always take it that they’d hardly slept because they knew that the next day they had to come in and tell someone they needed an abortion.
I had 18 patients on my own today, I do everything - vital signs, procedures, discharge. Dr Hans assists me, but I would love for another nurse to have the training too. Dr Hans is the chief clinician here and oversees everybody. He can’t take charge of the clinic on his own. It would be better if a registered nurse, like me, takes charge of it. It means that the nurse will carry out the procedures as well as the family planning and health education. I don’t want the woman to be going all over the place. I want her to have everything done in one visit.
At the moment of an abortion, the woman just wants to get rid of the problem. It’s fine to do a quick procedure but we need to help with the after care. I always worry in particular that young people will forget to take the pills. I always say that I don’t want to see them in this situation again and plead with them to use a long acting method so that they don’t have to end up seeing me again.
Although no one at the facility supports me, they do treat me with a lot of respect. I’ve never felt that I’ve been discriminated. But if a patient comes and I’m not there, they tell the woman to come back when I am around. They never shun her but they do keep anyone they think is related to reproductive health at arm’s length. It upsets me that people don’t get seen just because I’m not here.
It will be a shame that one day, this service could collapse because I’m gone. The reality is the service needs to stay, the clientele is getting bigger and we need people to be trained but we can’t get people to go for training. People refuse for religious reasons. I understand, I know that at the start it is difficult, but it’s important to learn to look at it differently and think about what the women really need.
Sumaya Joseph, a midwife from the Midwifery Obstetrics Unit in Maccassar, South Africa
I used to describe my work as catching babies. But the truth is that it is much tougher than simply catching babies. My workload is unpredictable and I need to be prepared for any eventuality.
The midwives here, and at many maternity units around the country, frequently work without the support of a doctor in emergency situations. Yesterday a woman came in with high blood pressure and she was 8cm dilated. We realised that she wouldn’t make the trip to the referral hospital. I called the doctor at the hospital and she gave me instructions over the phone and we cared for the patient here.
The outcomes are not always good though, and there are many stillbirth cases. Our unit is set up for normal deliveries so doesn’t have a separate area away from other mothers and babies for women who have stillbirths, which is traumatic for them.
I believe that many of the problems women face are because of poor pregnancy planning and not having access to proper services at the right time. We typically offer two or three month injections or pills. But many who deliver here are still in school. They can’t come every three months for the injection. We should really offer them a long term solution that would cover them for a longer time.
We don’t have practical training in inserting long-acting reversible contraception (LARCs), so we do not feel confident inserting them. I think patients will definitely take up the offer of LARCs. It means that as a midwife, I can give my patients something that they want. None of my patients want to be pregnant again in three months. It’s obvious to me that the ideal time for inserting an IUD or implant would be immediately postpartum. I am looking forward to offering this new service.
I know there will be other midwives who will be willing to be trained. Some are concerned that there will be too much blood postpartum, but I reassured them that they will be taught everything and that doctors are doing it the same way and I will continue to reassure them they can do this simple procedure. We just need training and continued support to help us feel confident.