By Val Truby, Leading Safe Choices Programme Manager, South Africa
In South Africa abortions were legalized in 1996, allowing women to exercise their rights over their bodies to terminate their unintended pregnancies safely at designated government facilities. Despite having one of the most progressive abortion laws in the world, including the right to terminate pregnancies on demand up to 12 weeks and under certain circumstances up to 20 weeks, unsafe and illegal abortions remain a significant public health problem in South Africa.
The RCOG Leading Safe Choices programme, in partnership with the Western Cape Government, seeks to strengthen the competence and raise the standing of abortion care professionals. A three day Comprehensive Abortion Care (CAC) class room training course, is followed by clinical mentorship in CAC under the supervision of an experienced mentor until trainees are signed off as competent.
Many health care providers in South Africa are resistant to providing abortion care services, citing conscientious objection. Those healthcare providers who are willing to provide CAC services are stigmatised by their colleagues and exposed to burn out due to the lack of adequate, competent backfill staff in this field of expertise. To address these challenges the Leading Safe Choices programme initiated Values Clarification workshops.
Values Clarification workshops allow healthcare professionals a safe space, in which they can explore their personal doubts and concerns about reproductive health issues, empathize with women seeking abortion care services and acquire knowledge to reaffirm their own values. The workshops further allow participants to develop the necessary skills to provide respectful, holistic care to those women seeking abortions.
All cadres of healthcare professionals including facility managers are included in the Value Clarification workshops as patients are exposed to the whole team on the care pathway and there is a need to address possible barriers at all levels. In addition, the workshops help to encourage support for abortion care providers from the rest of their colleagues who are not directly providing the service, addressing stigmatisation and working in isolation.
Each workshop comprises of 20 participants, and include group sessions, reflecting on scenarios, completion of individual questionnaires and lectures. Participants vote anonymously on a variety of questions and statements on abortion and abortion related issues, which is followed by frank discussion. The respectful environment established by the facilitator is key to encourage active participation, honest feedback and being non-judgemental toward fellow participants.
The objectives of the course are to allow participants to: distinguish between assumptions, myths and realities about unwanted pregnancy, abortion and the women and families who experience them; explain correct information about abortion and the circumstances surrounding it; demonstrate empathy toward the women, families and HCP’s who experience abortion; identify the values that inform their current beliefs and attitudes about abortion and be able to describe alternative values and their consequences; and, separate personal beliefs from professional roles and responsibilities in advocating for or providing abortion services.
I have trained 70 staff members since June this year and an increased request for these workshops is being observed. Whilst the workshops were attended by various categories of nursing and non- medical staff, the trend is slowly changing and senior managers are also attending. This has been an important shift as it was evident that managers at various levels in Leading Safe Choices health facilities in South Africa were very resistant to provide CAC services at their facilities, were resistant to send their staff for the CAC training and were unsupportive of current CAC providers. Some pharmacists were also resistant to procuring medication for Medical Abortion due to conscientious objection. Only a handful of CAC providers were providing the services and, should they leave, no succession plans were in place.
Alongside facility management attending Values Clarification workshops, the Leading Safe Choices programme has initiated monthly meetings with relevant managers to monitor progress of the CAC trainees and the continued attendance at the Values Clarification workshops. Recruitment of a dedicated CAC mentor has improved the responsiveness of some managers to support CAC service providers on the ground. Senior managers are now requesting that all their facility and operational managers attend the Values Clarification workshop in an attempt to transform attitudes and improve access to CAC services. The number of training requests for CAC has increased and the roll out of Values Clarification workshops is a contributing factor to this.
In order to determine the level of attitude transformation over time, we will conduct follow up of staff who attended the Values Clarification workshops. Measuring attitude transformation must be considered carefully; results would be the roll out of new services, improvement of quality of CAC services on the patient pathway of care, increased attendance of CAC training and the support of current CAC providers.
The provision of Values Clarification workshops create a safe platform for staff to voice their concerns regarding abortions and abortion related issues, address the provision of respectful, holistic care to women seeking abortion care services and dispel the myths that further cause barriers to access. Short term impact can be measured by the increased numbers of trainees attending the CAC courses and roll out of the CAC services after achieving competency. Previously the training was only attended by registered nurses but for the first time in history, registered midwives are also attending the training and are eager to roll out CAC services.
Values Clarification workshops should be integrated into existing CAC training packages. They are a mechanism to recruit new CAC providers, support existing providers and aims to increase access to safe abortion care services and saving the lives of women and their children.