A Pastoral Intervention Model For Abortions In Mangaung Metroplitan City

CONTENTS

CHAPTER 1: INTRODUCTION
1.1 BACKGROUND
1.2 RESEARCH PROBLEM AND QUESTION
1.3 RESEARCH SUB-QUESTIONS
1.4 LITERATURE
1.5THE VALUE OF THE STUDY
1.6 RESEARCH DESIGN AND METHODS/TOOLS
1.6.1 Research design
1.6.2 Research methods/tools

CHAPTER 2: A REVIEW OF LITERATURE ON THE LEGAL, MEDICAL, ETHICAL, THEOLOGICAL, AND PSYCHOLOGICAL ISSUES SURROUNDING ABORTION
2.1INTRODUCTION
2.2 CONSTITUTION OF THE REPUBLIC OF SOUTH AFRICA,NO 108 OF 1996 AND THE CHOICE ON TERMINATION OF PREGNANCY ACT,NO 92 OF 1996(COTP)
2.3 MEDICAL FACTS AND PERSPECTIVES ON ABORTION
2.4 ETHICAL AND THEOLOGICAL PERSPECTIVES ON ABORTION
2.5THE IMPACT OF ABORTION ON THE PSYCHOLOGICAL AND SPIRITUAL WELLBEING OF THOSE THAT HAVE THEIR PREGNANCIES TERMINATED AND HEALTH PROFESSIONALS WORKING IN THE TERMINATION OF PREGNANCY UNITS 34 2.6CONCLUSION

CHAPTER 3: COTP COUNSELLING FOR HEALTH PROFESSIONALS AND CLIENTS IN THE TERMINATION OF PREGNANCY UNITS IN THE PUBLIC HOSPITALS IN MANGAUNG METROPOLITAN CITY
3.1INTRODUCTION
3.2WHY THE AVAILABILITY OF COUNSELLING IS IMPORTANT
3.2.1 Introduction
3.2.2 Abortion is a crisis event for the client
3.2.3 The spiritual and/or psychological stresses health professionals experience while working in the termination of pregnancy units
3.3 PRESENTATION AND CRITIQUE OF THE COUNSELLING PROVIDED IN COTP
3.3.1 Counselling specified in COTP
3.3.2 Definitions of counselling (including Christian counselling)
3.3.3 A counselling definition most suited in the abortion context
3.3.4 Evaluation of counselling in COTP
3.4THE EMPIRICAL RESEARCH INTO THE COUNSELLING AT THE PUBLIC HOSPITALS IN MANGAUNG METROPOLITAN CITY
3.4.1 Design and methods of the research
3.4.3 Results of the research
3.4.3.1 Results of the research among the clients
3.4.3.2 Results of the research among the health professionals (nurses)
3.4.3 Discussion of the results
3.5CONCLUSION

CHAPTER 4: THE VIEWS AND EXPERIENCES REGARDING ABORTION OF HEALTH PROFESSIONALS AND CLIENTS IN THE TERMINATION OF PREGNANCY UNITS IN THE PUBLIC HOSPITALS IN MANGAUNG METROPOLITAN CITY
4.1 INTRODUCTION
4.2THE PLACE OF ETHICS, VALUES, AND WORLDVIEW IN THE TERMINATION OF PREGNANCY
4.2.1 Definitions of ethics, values and worldview and their interrelationship
4.2.2 The definition of Christian ethics, values and worldview
4.3 THE EMPIRICAL RESEARCH INTO THE VIEWS AND EXPERIENCES OF HEALTH PROFESSIONALS AND CLIENTS AT THE PUBLIC HOSPITALS IN MANGAUNG
4.3.1 Introduction
4.3.2 Results of the research among the clients
4.3.3 Results of the research among the health professionals
4.4 DISCUSSION OF THE RESULTS
4.4.1 Discussion of the results of the research with the clients
4.4.2 Discussion of the results of the research with the health professionals
4.5CONCLUSION

CHAPTER 5: A BIBLICALLY FAITHFUL THEOLOGY OF HUMAN LIFE AND WHETHER TERMINATION OF PREGNANCY ON DEMAND CAN EVER BE JUSTIFIED
5.1INTRODUCTION
5.2 MEDICAL AND NON-THEOLOGICAL CONSIDERATIONS IN DECIDING WHEN HUMAN LIFE BEGINS
5.3 PRO-CHOICE THEOLOGICAL VIEWS
5.4 PRO-LIFE THEOLOGICAL VIEWS
5.5EVALUATION
5.6 CONCLUSION

CHAPTER 6: A PASTORAL INTERVENTION MODEL FOR SERVING AND GUIDING HEALTH PROFESSIONALS IN THE MANGAUNG METROPOLITAN CITY GOVERNMENT ABORTION CLINICS AND WOULD-BE OR POST-ABORTION CLIENTS
6.2THE NEED FOR A MODEL IN THE MANGAUNG METROPOLITAN CITY CHURCHES REGARDING ABORTION
6.2.1 The findings regarding the biblically faithful normative position on abortion
6.2.2 The findings of the empirical research and some additional reflections
6.2.3 The pastors and congregations are falling short
6.3A MODEL FOR CONCEPTUALIZING HOW A BIBLICALLY FAITHFUL OPERATIVE THEOLOGY REGARDING ABORTION CAN BE ACHIEVED IN THE CHURCHES AND RESIDENTS OF MANGAUNG METROPOLITAN MUNICIPALITY
6.3.1 Introduction
6.3.2 Other effective church models
6.3.2.1 Hollinger's model
6.3.2.2 Allen's pastoral ministry model
6.3.3 A model for the Mangaung Metropolitan City churches
6.4THE STRATEGIC PLAN TO ACHIEVE THE MODEL FOR THE CHURCHES IN THE MANGAUNG METROPOLITAN CITY
6.4.1 Communicative strategy
6.4.2 Strategy for implementing the model
6.5 SUMMARY AND CONCLUSION

CHAPTER 7: SUMMARY AND CONCLUSION
7.1INTRODUCTION
7.2 REVIEW OF THE OBJECTIVES OF THE STUDY
7.2.1 Literature survey
7.2.2 Empirical research
7.2.3 Normative position
7.2.4 Pastoral model
7.3THE ARGUMENT
7.4THE FINDINGS
7.4.1 Literature survey
7.4.2 Present situation
7.4.3 Preferred situation
7.4.4 A model to move the present to the preferred situation
7.5THE LIMITATIONS OF THE STUDY AND RECOMMENDATIONS FOR FURTHER RESEARCH

APPENDIX 2: QUESTIONNAIRE FOR THE CLIENTS

APPENDIX 3: AN ARTICLE BY DR PRINSLOO, A PSYCHIATRIST, ON

POST-ABORTION PATHOLOGY

BIBLIOGRAPHY

MCALL K AND WILSON WP 1987. RITUAL MOURNING FOR UNRESOLVED GRIEF AFTER

ABORTION

Acknowledgements

First and foremost I would like to thank God our Father,the Lord Jesus Christ and the Holy Spirit for salvation, wisdom, guidance and courage to be ableto complete this work.

AtthispointofmyacademicjourneyI want to acknowledge my father, the Rev Pheello Phillip Musapelo-Makoetlane, who encouraged me to pursue education, instilled in me faith in the Lord and set a sacrificial example of a pastor - a father in the faith to many. My dear wife Moki Rebecca Musapelo spent nights sitting next tometoencouragemeandprayedformeasI journeyed along this challenging road. Thanks to Moki for her unwavering support without which this work could not have been completed. The leadership of Dynamic Life Pentecostal Church of Christ, who sacrificially labour in the vineyard of the Lord with me, fully paid my MTh fees, for which I thank them (Pastors Lefu Maphalla and Rebecca Musapelo, the Minister Mokhele Mojaki, and the other Elders, Dr Rosaline Sebolao, Nombulelo Modise, Nyakalloo Matsoso, Tebello Maphalla, andKerileng Pitlel).

I also wish to acknowledge those who have supported me in the writing of this thesis. Without them this would never have been possible. My supervisor Rev Vernon Light, encouraged me and kept me on track. Thanks Rev Light for the major role you played in this project. Thank you Dr Sethulego Matebesi for your assistance in providing guidance in the analysis of the results of the empirical research.

Others I wish to thank are The Head of Health: Free State, Dr David Motau for giving approval to conduct research in the health facilities of the Department of Health; my friend Dr Motsamai Motsoari who encouraged me to embark on the master's programme and continued to inspire and challenge me to complete it. Dr Monyake Moletsane who also encouraged me during the early stages of my journey on this road.

Finally I thank the participants who voluntarily allowed me to engage them and use their experiences for this thesis.

Abstract

The termination of pregnancy in South Africa has become a controversial issue affecting communities and the health professionals since the implementation of the Choice on the Termination of Pregnancy Act 199 (COTP). This Act has imposed a moral dilemma for many health professionals and for many contemplating abortion. This has come about in that it provides for abortion on demand in the first trimester. It has also caused many Christian pastors and other citizens great concern due to the rise in the number of abortions. As a pastor, this prompted me to relook at the issue of unwanted pregnancies and their termination from a theological perspective against the background of the Act and my pastoral concern. The failing family planning programme of the Department of Health has contributed to this moral controversy as some women use the termination of pregnancy as a birth control method.

This study starts with a literature review to highlight the various facets and views surrounding the explosive issue of abortion on demand. This opens up the parameters within which this matter needs to be engaged. Then the details of an empirical research conducted at three designated facilities of the Department of Health in Mangaung Metropolitan City are presented. The health professionals that conduct abortions (see chapter 3) were interviewed as well as sixty clients that underwent this procedure under their service. The research investigated both groups' experience under COTP. It explores not only the counselling side, but also reasons for abortion and related emotions and concerns of both health workers and clients. Further, the research probes their religious views and church attachments (if any) and how they relate to this controversial issue.

Then the two main theological views on termination of pregnancy on demand are considered. This part of the study seeks to arrive at a biblically normative position. It takes into account the biblical worldview and the high view it places on human life. It concludes that the pro-life position, Christian morals and moral regeneration, and family planning should be central programmes, and are crucial in dealing with abortion on demand.

Finally there is a formulation of a pastoral intervention model for the pastors in the churches in Mangaung Metropolitan City with some attention to recommendations for the Department of Health to address re3garding the ethical dilemma some health professionals face with reference to participation in any phase of the termination of pregnancy (intervention and nursing related to post-abortion complications).

Chapter 1: Introduction

1.1 Background

The issues relating to the implementation of the Choice on Termination of Pregnancy Act No 92 of 1996 (it will be abbreviated to COTP) in South Africa came to my attention when I was Chief Executive Officer of Universitas Academic Hospital and a member of the Executive Management of the Clinical Cluster in the Department of Health. The Clinical Cluster Management was informed that there were ethical issues threatening service delivery at the National District Hospital in Mangaung Metropolitan City.

The doctors working for the Department of Family Medicine (an academic department that forms part of the academic platform that was under my management) were expected to do some work at the casualty section of National District Hospital Casualty and also at the Reproductive Health Unit (where termination of pregnancies is done). Some of the work in casualty was to attend those who after abortion was initiated had a bleeding problem. These doctors who were in the majority refused to perform this work. This was because they were conscientious objectors with regards to the termination of pregnancy on demand.

They faced the wrath of hospital management, to the extent that one of them was charged with misconduct and dismissed from public service amidst the chronic shortage of doctors. He was, however, reinstated after he won a legal battle. The management of the institution also faced pressure because they needed to provide this service to implement the policy of the government (COTP).

The hospital then adopted a policy that all doctors that are being interviewed for positions be informed that they will be expected to perform termination of pregnancy procedures. This policy failed as the hospital was unable to attract doctors prepared to terminate pregnancies on demand. The situation also affected the nurses who were conscientious objectors. The Department of Health then considered out-sourcing this service to Marie Stoples, a company working exclusively in the abortion industry with numerous abortion clinics, because of resistance and antagonism from health professionals and management.

Due to being a Pastor in a church in Mangaung Metropolitan City, I have come across women who confided in me that they are haunted by the voluntary termination of their pregnancies made possible through COTP. They were in moral and emotional crisis. Many health professionals now face a moral dilemma due to the COTP. This created a curiosity and concern in me to want to understand in depth the ethical issues that have created this moral dilemma and an appropriate pastoral response.

Thus this background inspired me to undertake a study (i) related to these matters in order to fully understand the issues at play here, and (ii) as a pastor and practitioner of practical theology to develop a strategy to address this matter in Mangaung Metropolitan City. The hallmark of practical theology is the identification of a biblical undesirable life situation and development of a practical strategy, a framework or a model, to address the undesirable situation and change it into a biblically faithful life situation (Cowan 2000).

1.2 Research problem and question

The problem which this study focuses on is the moral/ethical issues and sometimes problems facing health professionals in the termination of pregnancy units of the Public Hospitals in Mangaung Metropolitan City (Botshabelo District Hospital, DR JS Moroka District Hospital and National District Hospital) and those contemplating abortion or who have had one or more such procedures at these hospitals. The interest is particularly with those professing to be Christians. This research seeks to answer the question, “What pastoral intervention model should be proposed for pastors and churches to serveChristian health professionals and their clients in this city with the moral dilemma or moral implications of terminating a pregnancy on demand with the backing of COTP?” The research does arrive at such a pastoral model and thus the thesis statement of this study is that a biblically faithful pastoral model can be developed for the churches in Mangaung Metropolitan City for ministry to health professionals and those contemplating an abortion or who have had one or more.

1.3 Research sub-questions

To answer the research question and thus solve the research problem, the following sub-questions were answered:

1.3.1 What is the range of legal, medical, ethical, theological and psychological perspectives on abortion on demand?

1.3.2 What type of counselling is presently available in the government's termination pregnancy units for clients (pre-abortion and post-abortion) and health professionals?

1.3.3 How do the clients and health professionals findg the counselling stipulated in COTP?

1.3.4 What are the views of the clients and health professionals regarding abortion, including their moral convictions, especially those who are Christians, and any emotional and moral dilemmas?

1.3.5 What theological perspectives and biblical guidelines can be derived from passages relevant to the abortion issue?

1.3.6 What are the proposed main components of a pastoral intervention model for pastors for dealing with Christian health professionals and clients in Mangaung Metropolitan City with the implications of and moral dilemma with the termination of a pregnancy and living with the memory of this act?

1.4 Literature

There is a voluminous amount of literature available nationally and internationally covering the termination of pregnancy or abortion from theological and secular perspectives. The literature search did not reveal any study tailored for the context in Mangaung Metropolitan City. The review of key literature presented in chapter 2 covers a wide representation of relevant scholarly literature pertinent to the research problem.

1.5 The value of the study

The major value of this study is that it tackles a controversial issue from legal, medical, moral, theological, biblical and social perspectives. Further, because the study was conducted with special reference to health professionals working in the abortion clinics in three government hospitals in Mangaung Metropolitan City and their clients (where most from both groups profess to be Christians), it is contextually relevant and therefore valuable to pastors ministering in this city.It also argues for the pro-life position as being the most faithful to the will of God which most Christians would uphold and defend. Thus it provides a valuable tool for any church, not only in Mangaung Metropolitan City, for understanding the theological-biblical teaching and the challenge of COTP.

Another great value of this study is that it presents a comprehensive model for seeking to establish a biblically faithful praxis that deals with unwanted or unplanned pregnancies and their avoidance in Mangaung Metropolitan City. Finally, the model developed also includes relevant teaching and counselling for Christian health professionals and those considering an abortion or dealing with post-abortion complications and unsettling issues.

This study will assist the health professionals, health managers, and health policy developers to understand the impact of moral convictions on health professionals working in the termination of pregnancy units and their clients, thereby facilitating an appropriate intervention. It will empower not only pastors, but also the average believer to offer assistance to those people that are experiencing a moral dilemma during pregnancy or if planning the termination of a pregnancy or if dealing with post-abortion reflection or distress. In summary, the study will add value to both pastors, counsellors, advocacy groups interested in this area, and the churches as they will be better positioned to minister to health professionals and clients caught up in the abortion scenario.

1.6 Research design and methods/tools

1.6.1 Research design

The research design chosen for this study was a modified version of the one utilised at the Loyola Institute of Ministry referred to as the LIM Model. This model of practical theology was developed by Cowan in Loyola Institute of Ministry. Cowan explains the key features of practical theology research as follows:

The hallmark of “practical theology” is the insistence that the point of theological interpretation is not simply to contemplate or comprehend the world as it is, but to contribute to the world's becoming what God intends that it should be, as those intentions have been interpreted by the great theistic tradition (2000:1).

The prevailing situation must be thoroughly analysed. The researcher must not only expose the present undesirable present situation and its context, facts and underlying theory, but must also propose an intervention to remedy the situation by developing a biblical normative approach.

Cowan (2000:1) emphasises that practical theology research has four important distinct features. It is correlational as it examines the two world positions or situations (the world as it is and the world as it should be). It is hermeneutical because it accepts the role of the interpretation of the situation in accordance with our faith tradition. It is critical because it “requires that we explicitly evaluate the inherited understanding that guides our interpretation and action”. Lastly it is transformational because its purpose is to harmonise the real world with the Creator's intentions.

The LIM model thus incorporates four sequential steps (Smith 2008:206). Firstly, a concern about a real-life problem in the world (church and/or society) is identified. In this study that life-problem was the possible psychological and spiritual effects of abortion on health professionals and clients in the government abortion clinics in the Mangaung Metropolitan City, especially those professing to be Christians.

Secondly, in the LIM model the world as it is in reality (the problem situation) is studied and interpreted (Smith 2008:206). In this study it required researching and analysing the practice of terminating pregnancies on demand: the reasons for, and the psychological and spiritual effects of abortion on the clients and health professionals in Mangaung Metropolitan City, most of whom claim to be Christians. The research also analysed the influence of counselling of health professionals and the effects of pre-abortion and post­abortion counselling of the clients according to the stipulations in COTP.

In the third step of the LIM model, the world as it should be is studied (Smith 2008:206). This was achieved by researching what would be the normative position in the light of the biblical revelation and relevant theological perspectives. This step benefits from a literature review of legal, medical, ethical, biblical, theological and psychological perspectives on abortion which preceded the first step of the LIM model.

The fourth and last step of the LIM model is the formulation of a feasible plan of action in order to achieve a remedy to the problem situation so that it is aligned with the desired situation (Smith 2008:206). In this study this step involved developing for church pastors a pastoral intervention model (i) to guide health professionals professing to be Christians in Mangaung Metropolitan City with the ethical problem (and related psychological and spiritual challenges) of terminating the pregnancy of clients, (ii) to counsel those with a pregnancy crisis and those who have had one or more abortions, especially those suffering spiritual or psychological stress, and (iii) better equip pastors to prevent abortion in their churches and the wider communities, and (iv) to impact Mangaung Metropolitan City and the Health Department to move towards the normative position.

The application of LIM model was the most suitable approach for this type of study. It is the most user-friendly model available in the field of practical theology with clear steps that logically progresses from one's concern about some church or community matter to a solution (Smith 2008:210-211). Though the matrix is simple and the steps described are quite basic, the model allowed for more in-depth research in each step. It also permitted the researcher to reflect and build on his or her own faith tradition when providing the theological solutions to a problem.

The chapter titles are as follows:

Chapter 1: Introduction

Chapter 2: Literature review

Chapter 3: COTP counselling for health professionals and clients in the termination of pregnancy units in public hospitals in the Mangaung Metropolitan City

Chapter 4: The views and experiences of health professionals and clients in the pregnancy units in public hospitals in the Mangaung Metropolitan City

Chapter 5: A biblically faithful theology of human life and whether termination of pregnancy on demand can ever be justified

Chapter 6: A pastoral intervention model for serving health professionals in the abortion clinics in the Mangaung Metropolitan City and would-be abortion or post-abortion clients

Chapter 7: Summary and conclusion

1.6.2 Research methods/tools

Chapter 2: Literature review

A review of literature covered the legal, medical, ethical, theological, and psychological issues surrounding abortion is presented as follows in the following categories: (i) the Constitution of the Republic of South Africa, Act no 108 of 1996 and the relevant operational Acts such as Choice on Termination of Pregnancy Act ( Act 92 of 1996); (ii) medical, ethical, biblical and theological perspectives on abortion, and (iii) the impact of abortion on the psychological and spiritual wellbeing of those that have their pregnancies terminated and health professionals working in the termination of pregnancy units.

The first category covered the legislative framework allowing abortion in South Africa and the limited non-compulsory counselling of clients and health professionals it stipulates. It also reviewed academic and other relevant responses to this legislation and the statistical figures of the number of resulting abortions and any other research on the impact of this legislation.

Chapter 3: COTP counselling for health professionals and clients in the termination of pregnancy units in public hospitals in the Mangaung Metropolitan City

This chapter looks into the methods and content of counselling provided at the abortion clinics at the public hospitals in the Mangaung Metropolitan City for health professionals and their clients. This data was sourced through empirical research. It covered all the nurses (six) handling or involved in abortions and a sample of sixty clients. At National District Hospital there were four professional nurses and one Medical Doctor in its termination of pregnancy clinic. At this hospital every method of termination is performed depending on the gestation period. In Botshabelo and Moroka Hospitals the units are staffed with only one professional nurse each as a medical doctor is unavailable and thus only medical abortions (see section 2.3) are performed. The counselling provided for in these clinics is supposed to be conducted according to government policy and procedures prescribed in COTP. The contents of counselling regulations are evaluated in accordance with the basic principles of Christian counselling as understood by Gary R. Collins in Christian Counseling ( 2007).

Chapter 4: The views and experiences of health professionals and clients in the pregnancy units in public hospitals in the Mangaung Metropolitan City

This chapter provides the results of empirical research into the experiences, values and moral convictions regarding human life and abortion of the six nurses and sixty clients. It also shows how abortion (whether conducting or undergoing it) impacts them.

The chapter, before providing the results of the empirical research, presents a discussion of and the interrelationships of worldview, ethics and values. It shows how worldview influences one's values and that together they impact one's moral or ethical choices. It then shows that a Christian should hold a biblical worldview and the resulting values and ethics. This excursion into worldview, values and ethics helpsindicate the worldview undergirding the surveyed nurses and clients' views and experiences regarding termination of pregnancy.

Chapter 5: A biblically faithful theology of human life and whether termination of pregnancy on demand can ever be justified

This chapter presents a theological reflection on the literature review chapter and provides a limited exegesis of passages of Scripture pertinent to the issue of abortion, like those on the value of human life and the commandment not to murder. This is conducted within a broad consideration of the pro-life theologians and pro-choice theologians' positions. Pertinent theological considerations are also provided and various scholarly works are consulted and critically engaged. However, there is also some focus on situations where sometimes Scripture seems to indicate that an unavoidable ethical choice would lead to the choice of the lesser of two ills.

The conclusion reached is that termination of pregnancy would, with rare exceptions, not be supported by Scripture. This means that the theological position that supports human life from the fertilization of the ovum is the one that the church should adopt. However, this approach needs to take cognisance of issues surrounding unplanned abortions, which happens in chapter 6.

Chapter 6: A pastoral intervention model for serving health professionals in the abortion clinics in the Mangaung Metropolitan City government and would-be abortion or post­abortion clients

The findings presented in chapters 2 to 5 are correlated in this chapter to enable the formulation of an intervention pastoral model for pastors of churches in Mangaung Metropolitan City to (i) to serve and guide health professionals, (ii) serve and guide girls and women contemplating an abortion or dealing with some distress afterwards, whether immediately or later, and (iii) provide churches with sound biblical teaching on the issue to help prevent abortions and to spread this message broadly into the wider society, including the Department of Health.

Chapter 7: Conclusion

The section provides the summary of the research (objectives, argument and results) and the suggestions for further research.

Chapter 2: A review of literature on the legal, medical, ethical, theological, and psychological issues surrounding abortion

2.1 Introduction

This chapter provides a review of a representation of scholarly literature on abortion. This includes literature dealing with the termination of pregnancy from theological and other perspectives. The bulk of literature on the termination of pregnancy or abortion in South Africa deals with the socio-economic questions surrounding abortion and other critical issues in the health care system stemming from COTP. In South Africa, unlike in many countries, even the United States of America, there is clarity with regard to the legal position pertaining to abortion.

The issue of abortion in theology has theologians who apply biblical texts to support it, at least in the first semester, and others that claim texts reject it. This study is particularly interested in the dilemma, if any, health professionals face working in the termination of pregnancy units in public hospitals in Mangaung Metropolitan City and their clients, especially those professing to be Christians. The literature review will, therefore, focus primarily on literature dealing with challenges flowing from moral/spiritual problems with abortion in the context of public hospitals in South Africa, especially those in Mangaung Metropolitan City.

The chapter, firstly, deals with the role of the South African Constitution in determining government policy with regard to abortion and related moral challenges and legal cases. Some key research is noted around the impact of the provision in SA for abortion freely up to a certain age of the foetus and thereafter in certain cases. Secondly, the literature review touches on the research that reflects on the ethical and theological issues pertaining to abortion on demand. Thirdly the literature review focuses on the studies that reveal the impact of abortion on the psychological and spiritual well-being of those that request and undergo abortion and the health professionals that provide the termination of pregnancy services. The chapter ends with a conclusion on the importance of the literature covered in each category of the literature review and the contribution it will make in the subsequent two chapters of the study.

2.2 Constitution of the Republic of South Africa, No 108 of 1996 and the Choice on Termination of Pregnancy Act, No 92 of 1996 (COTP)

The Constitution of the Republic of South Africa in the Bill of Rights section allows for the right to termination of pregnancy. Section 12(2)(a) states that “everyone has the right to bodily and psychological integrity, which includes the right - to make decisions concerning reproduction; (b) to security in and control over their body.” Section 27(1)(a) states, “Everyone has the right to have access to health care services, including reproductive health care.” The constitution does not use the word abortion. However, it clearly implies this as a right as is shown in COTP, which gives expression to intention of the Constitution on this matter.

COTP declares in Section 2 the circumstances under which abortion may be performed:

A pregnancy may be terminated - (a) upon a request by a woman during the first 12 weeks of the gestation period of her pregnancy; (b) from the 13th up to 20th week of the gestation period if the medical practitioner, after consultation with the pregnant woman, is of the opinion that the - (i) the continued pregnancy would pose a risk of injury to the woman's physical or mental health; or (ii) there exists substantial risk that the foetus would suffer from physical or mental abnormality; or (iii) the pregnancy resulted from rape or incest; or (iv) the continued pregnancy would significantly affect the social or economic circumstances of the woman; or (c) after 20th week of the gestation period if a medical practitioner or a registered midwife, is of the opinion that continued pregnancy - (i) would endanger the woman's life; (ii) would result in a severe malformation of the foetus; or (iii) would pose a risk of injury to the foetus.

This Act includes the following (emphasis added for greater clarity on the main sections):

Place where surgical termination of pregnancy may take place 3. (1) The surgical termination of a pregnancy may take place only at a facility designated by the Minister by notice in the Gazette for that purpose (2)

The Minister may designate any facility for the purpose contemplated in subsection (1), subject to such conditions and requirements as he or she may consider necessary or expedient for achieving the objects of this Act. ... (3)The Minister may withdraw any designation under this section after giving 14 days' prior notice of such withdrawal in the Gazette. Counselling 4. The State shall promote the provision of non-mandatory and non-directive counselling, before and after the termination of a pregnancy. Consent 5. (l) Subject to the provisions of subsections (4) and (5), the termination of a pregnancy may only take place with the informed consent of the pregnant woman.

The Act also states the procedures that must be followed before, during and after the termination of pregnancy. It further designates the qualifications of the health professionals permitted to perform the termination of the pregnancies. It also provides the penalties for non-compliance with it. The termination of pregnancy in all public health facilities in South Africa is performed in accordance with the provisions of this act.

This legislation brought remarkable departure from the previous legislation called the “Abortion and Sterilization Act 2 of 1975” and its subsequent amendments. The latter Act was not as liberal as COTP. It required three doctors to make an unanimous decision concerning the condition of the pregnancy and conditions that resulted in this pregnancy, and only if the continued pregnancy endangered the life of the pregnant woman or was posing a serious threat to her physical or mental health or if there was a serious risk of the child suffering an irreparable handicap or severe mentaldefects, or if the conception was through unlawful or illegitimate carnal intercourse. This decision of the doctors was to be reduced to writing before abortion could be executed.

The COTP is fully accepted by the Government and the Department of Health as the implementing agency, but the people of South Africa still do not generally accept termination of pregnancy. At least this was the case in 2006: “In spite of the legalisation of abortion twelve years ago, most South Africans are of the view that this practice is ‘wrong'” conclude Mncwango and Rules (2006:6).

It is important to note that the oath for medical doctors, called the “Hippocratic oath,” does not support the termination of pregnancy. It states that the doctor “will exercise the art of medicine solely for the cure of my patients, and will give no drug, perform no operation for criminal purpose, even if solicited, far less suggest it; in like manner I will not give to a woman any kind of a strange material to procure abortion, and I will maintain respect for life from the moment of its conception” (Hippocratic Oath n.d.). The Hippocratic Oath has been revised several times and the South African Medical Association adopted the new version called “A pledge” on the 16th of October 2017: “The South African Medical Association (SAMA) today joins thousands of physicians around the world in welcoming a modern successor to the Hippocratic Oath” (South African Medical Association 2017). It excludes any reference to preserving the foetus.

The South African Nursing Council ([2018]) stipulates in the Rights of Nurses as follows:

In carrying out his/her duty to patients, the nurse operates within the ethical rules governing the profession and his/her career scope of practice.

The confirmation of the rights of the nurse is therefore not an end in itself, but a means of ensuring improved service to patients. To enable the nurse to: provide safe, adequate nursing, he/she has the right to:

7. conscientious objection provided that:

- the employer has been timeously informed in writing
- it does not interfere with the safety of the patient and/or interrupt his/her treatment and nursing

The words, “To enable the nurse to provide safe, adequate nursing, he/she has the right to: ... 7. conscientious objection”, seem to harmonize with the above Hippocratic Oath (original version) that protects life from inception. The new version of the Hippocratic Oath called “A pledge” still pledges to maintain human life: “I WILL MAINTAIN the utmost respect for human life” (Parsa-Parsi 2017:1). This could be taken to refer to life from its beginning at conception. This view is supported as follows:

Even without referencing abortion directly, the doctors who take this oath - if they're honest - are still committing themselves to the preservation of human life, which traces all the way back to conception. The fact that countless abortionists have blithely bound themselves to this oath doesn't negate its original intent. We can change the language of historic moral documents - to accommodate an ethically-suspect practice, but we can't change the morality itself. Simply put, killing an innocent human being is not a morally-acceptable cure to unwanted pregnancy (Abortion and Hippocratic Oath 2018).

However, the Rights of Nurses also allow for involvement in termination of pregnancies.

This is seen in the press statement by the Registrar of the South African Nursing Council (Subedar 2004):

Neither the Choice on Termination of Pregnancy Act, 1996 nor the Nursing Act, 1978 and the South African Nursing Council compels a nurse to conduct a termination of pregnancy. The intention of the Act is to provide a choice for women regarding the termination of a pregnancy and to enable a medical practitioner and a registered nurse to carry out such a termination. A Registered Nurse has a choice to undergo the prescribed training and furthermore he/she also has a choice regarding whether to work in a facility that is approved to carry out a termination of pregnancy.

A crisis in health care arises if the conscientious objector to abortion is nursing in a ward where someone with after-abortion medical complications lands up for treatment in the ward. The second bullet point under ‘conscientious objection” in the Rights of Nurses would seem to demand medical care in this situation and thus complicity in abortion. The situation presents an opportunity for further study, which my study will touch on.

In 2009 a pro-life doctor, Dr Faan Oosthuizen, was dismissed by the Free State Department of Health for participating in the protest against the termination of pregnancy. The doctor protested because he and others were made to participate in the termination of pregnancy or complete the process of termination of pregnancy started by his pro-choice colleagues. He objected and protested based on his religious belief and his constitutional right to conscientious objection. He was reinstated by the CCMA in 2010 (Anti-abortion doctor re-instated 2010).

The COTP Act was challenged in court by the Christian Lawyers Association of South Africa and others (Christian Lawyers Association of South Africa and Others v Minister of Health and Others, 1998). It was based on the ground that the termination of pregnancy is against the constitutional right of the foetus' to right to life. The court dismissed this case by stating that the constitution does not confer the right to life to the unborn child. The judgement explains that the constitution of the Republic of South Africa does not make an expressed provision granting the unborn child legal personality or protection. The ruling further explains that it is inconceivable that such an important provision was omitted if the constitution was to enshrine the right of the unborn child, particularly when there are no provisions about this in the existing common law. The provision of section 28 of the constitution that grants the protection to the child is not extended to the to the unborn child, therefore section 11 is unlikely aimed at protecting the foetus. Also, all rights granted to post-birth humans clearly cannot be applied to foetuses.

This decision of the court was not appealed. As a result the legal issues relating to the termination of pregnancy as provided in the constitution and COTP make it constitutional and legal for a pregnant woman to choose to terminate a pregnancy in South Africa during the first twelve weeks of pregnancy. After this stage certain conditions need to fulfilled, but they include more liberal ones than were stipulated in the Abortion and Sterilization Act 2 of 1975.

In the case State v Mshumpa (Pickles 2012:42.) both Mshumpa and Best were accused of planning the murder of the foetus by shooting at the stomach of the pregnant girlfriend of Best that caused the stillbirth of the baby (foetus). They were both charged with the murder of the foetus. The court found that they could not be found guilty of murder as the killing of the foetus does not fall within the definition of murder. The person killed should have been born to be killed; the foetus is not yet born. This finding of the court affirms that the foetus does not have the same status as the born person according to the constitution of the Republic of South Africa.

A study by Harries (2010) looked at the challenges and barriers related to safe abortion in the Western Cape. One of the challenges for health professionals was the disregard of the freedom of religion and conscience guaranteed in the constitution of the Republic of South Africa as stated in chapter 2 section 15(1): “Everybody has the right to freedom of conscience, religion, thoughts, belief and opinion”. However, health professionals find themselves compelled at work to provide abortion on demand. This situation needs further discussion and research to understand the extent of the problem and find a solution that can accommodate conscientious and religious objectors. COTP is silent on the freedom of religion and conscience and this silence has led to controversies and uncertainties in the operational fields such as hospitals and clinics.

In the circular H97/2000: Provincial Administration: Western Cape: Termination of Pregnancy (COTP)Policy Guidelines and Protocols, the Department of Health, Malan (2000) explains how the conscientious or religious objectors should conduct themselves when they observe their constitutional rights: “Conscientious objectors should only be dealt with when expressed by an individual staff member, not a group action.” Taylor and O'Sullivan concur with this sentiment (2005:18). Employees can be encouraged to discuss possible conscientious objections electively. Refusal to discharge obligations when faced with a particular task could lead to breach of contract.” The last sentence in this quotation is noteworthy and very relevant to the conscientious/religious objector to abortion. It apparently means failing to initiate an abortion or conduct one surgically when asked and to do follow-up treatment/care that may be needed could lead to dismissal or facing some court action. It needs to be noted that conscientious objectors will also be uncomfortable with providing post-abortion emergency treatment as it can be seen as indirectly participating in the provision of abortion. The government should, therefore, develop the treatment protocols that make it clear policy that there will be no negative repercussions for the objectors to treating patients that were given abortions by medical or surgical procedures by their colleagues.

It is important to note the tone of the authority in the Western Cape circular mentioned above in its statement that conscientious objection should not be expressed via a group of medical health professionals but individually. This directive disregards the constitutional right of the freedom of expression and to belong to an association and through it express one's position that is held by the association.

Another study (Harries, Brahmi and Shah 2010) was conducted in the Western Cape in which the impact of conscientious objection on the access to safe abortion was analysed. The study revealed that the access to medical legal abortion is obstructed by the considerable number of health professionals who refuse to participate in the provision of abortion services by invoking their right to religious or moral objection as provided by the constitution. The application of this right by the health professionals is according to the study unregulated and becomes a barrier to safe abortion in the public health space. “It thus became evident that there were grey areas regarding staff refusing to participate in certain aspects of abortion provision and managers were accommodating providers' refusal of care rather than instituting a more coordinated approach to refusal of care such as requiring them to register for their conscientious objection and having a contingency plan in place” (p. 8).

Dr Rebecca Hodes (2016), who is a researcher on the history of abortion in South Africa, also observed that the provision of the termination of pregnancy services is posing serious ethical challenges to health professionals. The extent is seen in that some act in irrational and inhumane ways when dealing with clients who have aborted or seek abortion.

Research participants described how the denial of analgesics to abortion patients may be a strategy to punish women for having abortions, and to discourage them from seeking ‘repeat' abortion in the public health sector. As one doctor stated, ‘I do think that the pain medication, the analgesia, is not optimal . If you make it too comfortable, then people are going to come back .. (p. 88).

The study by Harries et al. (2010) presented the moral and religious grounds for objection as in conflict with the rights of women to freedom of choice with regard to reproductive health. The data collected from the sampled population of health care service providers dealing with the abortion, health care managers and health care policy influencers displayed the following interesting features: 79% of the respondents claimed to be affiliated to the Christian faith and 21% do not belong to a specific religion. The statistics by Statistics South Africa (Stats SA) (2016)indicate that 68% of the population of Mangaung Metropolitan City is made up of Christians. If the dominant view of Christians is against abortion on demand (chapter 5 comes to the conclusion that this should be the position Christians should take), then clearly the whole abortion industry cannot be conducted as envisioned by COTP. One responsible way for the government to approach this problem is to relook at the Act and let it be reworked to suit the majority view of Christians who according to the population census are in the clear majority.

The study by Harries, Cooper, Strebel, and Colvin (2014) highlights the problem of the following two conflicting rights that both need to be acknowledged: (a) the right to freedom of choice in relation to reproductive health by women and the termination of pregnancy as provided by both the constitution and the COTP Act, and (b) and the right to religious and moral conscientious objection as also provided by the constitution. It recommends that a middle ground must be developed in order to (i) increase the number of the health professionals that will provide the abortion services, and (ii) clearly depict the framework on how the objection to performing these services based on moral and religious grounds should be applied. It is obvious that the provision of the abortion services depends on the availability of health professionals who are willing to participate in this process. And if there are insufficient numbers of professionals willing to participate, then the COTP services will not be provided. Again, as argued above, one way for the government to approach this is to relook at the Constitution and COTP and deal with the matter of abortion from different moral and religious perspectives that better honour the right to life and discourage abortions and work consistently at improving moral, disciplinary and planning standards in society regarding sexual matters.

Sometimes those who opt for an abortion need medical treatment and nursing care in a hospital for complications. Christians would not want to deny this medical attention as to do so would cause suffering and potentially death and surely be unloving. The biblical story of the Good Samaritan comes to mind. Also government would seem to demand that health professionals are to provide this treatment. But, as already noted, treating such cases seems to imply at least implicit acceptance of abortion. The dilemma for the conscientious objector in South Africa, especially government hospitals, is clear. This study attempts to find a way that would prove helpful to the pastoral ministry of Christian leaders to health professionals faced with this dilemma, as well as to those contemplating abortion and who have undergone one or more.

2.3 Medical facts and perspectives on abortion

COTP states that termination of a pregnancy means “the separation and expulsion, by medical or surgical means, of the contents of the uterus of a pregnant woman.” It needs to be noted that the Act does not deal with a spontaneous abortion in which the products of conception are lost naturally, which is also called miscarriage. Spontaneous abortion is due to medical or physiological problems such as hormonal problems or weak uterus, and this is what is referred to as a miscarriage (cf. www.megaessay.com).

The other two types of termination of pregnancy or abortion are elective and therapeutic. The following shows the difference between elective and therapeutic abortions:

An abortion is considered to be elective if a woman chooses to end her pregnancy, and it is not for maternal or fatal health reasons. Some reasons a woman might choose to have an elective abortion are: continuation of the pregnancy may cause emotional or financial hardship, the woman is not ready to become a parent, the pregnancy was unplanned, the woman is pressured into having one by her partner, parents, or others, or the pregnancy was the result of rape or incest. A therapeutic abortion is performed in order to preserve the health or save the life of a pregnant woman. A health care provider might recommend a therapeutic abortion if the foetus is diagnosed with significant abnormalities or not expected to live, or if it has died in the utero. Therapeutic abortion may also be used to reduce foetuses if the woman is pregnant with multiples; this procedure is called multifetal pregnancy reduction - MFPR (Encyclopedia of Surgery [2017]).

The controversy about the termination of pregnancy is not around spontaneous abortion or therapeutic abortion where the woman's life is in danger through the pregnancy, but elective abortion or abortion on demand.

What follows now is a description of the different, and also the related, methods used to terminate pregnancies (elective abortion). Induced abortion is performed by use of a combination of pills and is called medical termination. The pregnancy that is up to 9 weeks will usually be terminated through medical abortion. It is the use of a combination of approved pills to bring to an end the process of pregnancy. In South Africa the Government working with Ipas (International Pregnancy Advisory Service)has allowed Mifegyne (mifepristone)pills to be first taken and Cytotec (misoprostol) to be taken 24­48 hours later(Medical abortion study guide 2013). This method of terminating the pregnancy and its medical process in the body is similar to miscarriage, as the woman will experience cramping, contractions, and bleeding as her body expels the pregnancy (cf. www.earlyabortion.comandMedical abortion study guide 2013).

Abortion by manual expulsion of the products of birth is the surgical termination of the pregnancy. One method is vacuum aspiration:

The high efficacy of vacuum aspiration, with complete abortion rates between 95 and 100%, has been well reported in several trials.

Vacuum aspiration involves the evacuation of the contents of the uterus through a plastic or metal cannula, attached to a vacuum source. Electric vacuum aspiration (EVA) employs an electric vacuum pump. With manual vacuum aspiration (MVA), the vacuum is created using a hand-held, hand- activated, plastic syringe. MVA has been in use for more than 30 years with varying opinions on its safety from different experts. However, some clinicians believe that women might prefer MVA to EVA because the procedure is quieter with no suction or machine noise and because it can be performed in primary care settings with a lower cost and more accessible service (Wen, Cai, Deng and Li 2008).

Vacuum aspiration is also appropriate for treatment of incomplete abortion up to 12 weeks from the last menstrual period (including miscarriage, spontaneous abortion and removal ofretained products from aninduced abortion) (cf. Medical abortion study guide 2013 and www.earlyabortion.com). “The practical disadvantage of this approach is that itis a form of surgery, and although it is relatively safe with the whole procedure taking about 15 minutes, there is some risk of infection and uterine injury” (Feiser 2017:1).

Another method of manual termination of a pregnancy is dilatation and curettage. “It is a medical procedure in which the uterine cervix is dilated and a curette is inserted into the uterus to scrape away the endometrium (as also used in the treatment of abnormal bleeding or for surgical abortion during the early part of the second trimester of pregnancy) - also called a D&C” (Merriam and Webster Dictionary; cf. World Health Organization 2012). It can be performed between 6 and 16 weeks of pregnancy. Use of this method is in decline now because of its higher costs and complication rate relative to the vacuum aspiration method. With fetuses between 15 and 20 weeks, a variation of this method is used, which involves dismembering and removing the fetus piece by piece with forceps (Fieser 2017:1). Pro-lifers would prefer not to use the term foetus at this stage or even earlier, but a human life in the early stages of development.

The following graphic pictures depict the process and results of abortion where dismembering is involved (the last two pictures only show the development of thefoetus) 06/09/2017).

(www.priestsforlife.org/resources/abortionimages/fetaldevelopment.ht)

Illustrations removed for copyright reasons.

Illustrations removed for copyright reasons.

11 weeks (picture taken of baby's feet in the womb) and 14 weeks (picture taken of babyin the womb)

The second trimester of pregnancy (also called mid-trimester) is the period from 13 to 28 weeks of gestation. It is subdivided into an 'early period' (between 13 and 20 weeks) and a 'late period' (between 21 and 28 weeks). Worldwide, 10%-15% of all induced abortions occur during the second trimester. Overall, two thirds of all major complications of abortions are attributable to those performed in the second trimester

Over the past 30 years there have been continuing efforts to improve abortion technology in terms of effectiveness, safety (lower complication risk), technical ease of performance and acceptability, with the optimal method for second-trimester abortion continuing being debated (Cheng 2008:1). However, there is an observation in this regard as explained by Cheng: “For second-trimester induced abortion, dilation and evacuation is superior to medical methods of abortion. However, specialized training and consistent practice are needed to perform this method safely.” This is also the observation of Cabezas (1999): “ Medical regimen had more side effects than surgical abortion, including bleeding, cramping, nausea and vomiting. Only fever was more frequent in the surgical method. The failure rates for medical abortion exceeded those for surgical abortion, 16.0% vs. 4.0%.”

Blue Ladies Clinics ([2017]) presents the following, making abortion sound so simple and innocent and no different to any other minor medical procedure like having a wart removed or a visit to the dentist for some treatment:

You lie down on a comfortable examination table in a private, colorful clean room. The doctor performs an ultrasound examination. The doctor inserts a speculum (like a pap smear). The doctor numbs the cervix with a local anesthetic. You typically do not feel this. The doctor stretches the natural opening of your cervix with small plastic dilators and inserts a thin tube, called a cannula and applies gentle pressure for one or two minutes. You may feel some mild to moderate period-like cramping at this time. The doctor removes the instruments. A second ultrasound is performed to ensure successful completion. You lie on the table for another 5-10 minutes. The cramps ease quickly. In a few more minutes you feel completely normal. You get dressed and resume your normal daily activities.

It is notable that there are no references to the ethical implications and possible psychological crisis flashbacks or permanent destructive guilt. There is an inexcusable silence that the often gory details of the process of abortion and its irreversible ending of life, even in the embryonic or very early stage and more so once a tiny identifiable human body, is present by the end of the first trimester.

The attitude of the women whose minds are made up to terminate the pregnancy is explained by Michels (1988:16) as follows:

A woman faced with unwanted pregnancy will often deny that the child developing inside her womb is a human being. Her doctor might call it a “product of conception.” Someone else might say, “it just a blob of tissues.” Both descriptions deny the personhood of the child.

2.4 Ethical and theological perspectives on abortion

The theological and ethical arguments against abortion and those supporting abortion are linked to the time whena foetus is considered a person. The pro­choice advocates argue that the law that protects the life of a human being would only apply to the foetus if it were a human being, which it is not. Geisler (2010:134) states that “it would be foolish dogmatism to rule in favour of the foetus being a person.” He claims that the Bible does not address this matter of a foetus being a person.

A research study (Van Vuuren 2001) was conducted among the abortion Christian counsellors in private pro-life clinics and pro-choice clinics to look at how they negotiate their values in abortion counselling. This study did not address the other health professionals such as doctors and nurses in public hospitals nor the clients. However, the influence of Christian values was detected among counsellors from both pro-life and pro-choice clinics. The study revealed that pro-choice abortion counsellors, though claiming to be Christians, reflect the values of theologians that support abortion on demand; and counsellors in pro-life clinics reflected the pro-life theological position.

In another study (Potgieter and Andrew 2004) the nurses that chose to work in the field of termination of pregnancy claimed to be Christians and further stated that it is pleasing to God for them to help needy women to terminate a pregnancy. In this study it also appeared that some ministers of religion support the nurses that work in the termination of pregnancy unit. This study, however, did not probe deep into the confession of the Christian faith of those nurses. It did not, for example, probe what Scriptures they applied to support their argument.

Professor Lategan (2006:122-123) notes that Reformed ethics holds the view that life starts at the point of conception, and therefore abortion is regarded as morally wrong. This does not mean that human life must be protected at all costs. However, socio­economic hardship or unwanted pregnancy cannot be accepted as reasons for the termination of pregnancy. Responsibility is the appropriate response, which “is essentially answering God's love for the unborn life.”

The pro-life theologians in their writings are consistent with the pronouncements of the early church through different councils and the writings of various Christian Fathers. The council of Elvira in 305 AD instructed the Christians against abortion in canons 63 and 68, which state, “If a woman becomes pregnant by committing adultery, while her husband is absent, and after the act she destroys [the child], it is proper to keep her from communion until death, because she has doubled her crime. And ... if a catechumen should conceive by an adulterer, and should procure the death of the child, she can be baptised at the end of her life” (Gorman 1982:64). These declarations in the canons endorsed by the council clearly indicate the pro-life stance of the early church and its attitude against abortion seen in the harsh treatment meted out against those church members who committed abortion.

The subsequent council of 314 AD addressed the question of abortion and made its stance known in canon 21, though it adopted a less severe penalty: “Women who prostitute themselves, and who kill the children thus begotten, or who try to destroy them when in their wombs, are by ancient law excommunicated to the end of their lives. We, however, have softened their punishment, and condemned them to the various appointed degrees of penance for ten years” (Gorman 1982:65). Further to the council's pronouncements, Basil of Caesarea, one of the fathers and theologians of the time, endorsed the earlier dictates of the council on the question of abortion (p. 66).

The important ethical issue is that the termination of the pregnancy can be viewed as the termination of life as the foetus is living and independent of the mother because it has different genetic code, has heartbeat at the 18th day, feels pain, and has a unique set of finger prints (Anderson n.d.:4). For the Christian, therefore, who takes this position, an abortion would be seen as murder which is prevented in one of the Ten Commandments. Again the dilemma facing health professionals, especially Christians, working in public hospitals (and perhaps to a lesser degree in private hospitals) is obvious. How should pastors approach their pastoral ministry to these workers and their clients? This study is a contribution to this debate and pressing ethical challenge.

2.5 The impact of abortion on the psychological and spiritual wellbeing of those that have their pregnancies terminated and health professionals working in the termination of pregnancy units

This study is focused on the situation facing health professionals and their clients in the abortion clinics responsible for abortions in three public hospitals in Mangaung Metropolitan City. To appreciate in part any dilemma the health workers might face, it is necessary to gain some insight into how facing, undergoing, and living after abortion affects the psychological health of younger and older women. This knowledge would be fully or partially known by the nurses and doctors working in abortion clinics. The findings of a study by Howard (2010) revealed that teenagers are expressing severe emotional torment caused by their abortions performed on them on demand in the designated facilities as prescribed by the law.

The results of Howard's study concur with that of another study (Kheswa and Takatshana 2014) undertaken to explore the impact of abortion on university students in South Africa. It also reported that students who had gone through an abortion experienced negative emotions such as guilt, emptiness and regrets. Their values and the type of pre-abortion or post-abortion counselling provided to them were not evaluated. Another study that looked into the emotional state of women who request an abortion discovered that these women experience crisis, dilemma, and anxieties and are also confused (Hupel and Strydom 2010:69). This area still needs to be further researched to find out the extent of the problems revealed in earlier research.

Similar symptoms have been noted by McAll and Wilson (1987:1): “We have accumulated clinical experience relating these experiences to the development of severe psychopathology that we believe arises out of unresolved grief. Abortions affect not only the women but also their ‘significant others'.” Prinsloo, a psychiatrist, has found in her practice that there is no absolute or single outcome regarding the mental health of women who terminated their pregnancies. Her main observation is that those clients who have pathology over their abortion/s have a religious belief that teaches abortion is a sin; and they cannot forgive themselves or think God will never forgive them. Those that can be helped to receive forgiveness from God and forgive themselves fare much better. The full article (2018) is in Appendix 3.

The above information gives some idea of the impact of abortion on clients, certainly negative in some or a significant number of cases. When this is grasped by health professionals working with abortion cases and their clients, it adds to their dilemma. This was confirmed in another study conducted in North-West Tertiary Hospitals that revealed that “some professional nurses experienced guilt, depression, anxiety and religious conflict as a result of providing TOP services” (Mokgethi, Ehlers, and Van der Merwe 2006).

A similar study (Mamabolo and Tjallinks 2010) was conducted in a health facility near Pretoria. It also found that registered nurses working in the termination of pregnancy units suffer the following symptoms: frustration, stress, being labelled, and a feeling of rejection. They claim that the nurses are not adequately debriefed, do not receive support from management, and hence experience emotional exhaustion. Still another research study (Englebrecht 2005:206) in the Free State found these and other impacts result for professional staff:

... that increasing feelings of guilt, resentment, and isolation, together with poor work morale and less positive attitude towards TOPS, all imply the longer health workers are involved in the providing the service, the more emotionally drained they become. In addition to this concern, the absence of psychological support for TOPS service providers in the province is worrisome.

The American Association of Pro-Life Obstetricians and Gynaecologists (AAPLOG) (2009) made a submission to the United Nations High Commission on Human Rights. The submission was prepared by Dr Harrison (2009), who in it notes that it is supported by Dr Yoshihara of Catholic Family and Human Rights Institute (p. 5). It argued against legalising abortion in countries that still regard abortion as illegal. It noted that the proposal to legalise abortion was based on the assumption that medical abortion on request will reduce the incidents of back-street abortions, thereby resulting in the reduction of maternal mortality and morbidity rate in the world. The submission by the AAPLOG provided detailed statistics from various studies to indicate that legal abortion does not lead to reduction in maternal mortality and morbidity rate, but increases this rate and those that survive present with medical complications such as pre-term births, bleeding, infections, psychological, and emotional problems. “Over 100 studies in medical literature demonstrate that women undergoing safe abortion have a significantly increased risk of subsequent suicide, major depression and substance abuse, as compared with women who bring to birth” (p. 5).

The World Health Organization (WHO) commissioned a study by Harries J, Brahmi D and Shah IH (2010) in Cape Town to uncover the factors at play in the provision of abortion services. The study found that pre- and post-abortion counselling was inadequate, and those health professionals who are willing to provide the termination of pregnancy were not themselves provided with counselling.

The study by Harries, Stinson, and Orner (2009) found that the counselling for health professionals is an important aspect of the termination of pregnancy service; however, it was found to be the missing ingredient. Not only clients, but also providers of abortion services need counselling: “... the psychological needs of the providers must be addressed as counselling and support are required for both providers and clients” (p. 10).

A study (Strydom and Hupel 2009) was undertaken in Potchefstroom Hospital where the importance of pre-abortion counselling was evaluated. It was found that those clients who were counselled before abortion have better understanding of their constitutional rights, namely, the decision to terminate or not to terminate a pregnancy. And when a decision is made it is not an impulsive but an informed one. However, in the light of the above, this does not mean that they will not potentially suffer psychological problems later. This is because at the time of making the decision to have an abortion it is not possible to know what the long term effects might actually turn out to be.

The studies referred to in section 2.4 indicate that the Constitution of South Africa and the COTP Act did not take sufficiently into account the post-abortion range of possible or likely negative outcomes on the psychological and spiritual health of both the clients undergoing abortion and health professionals providing it. In particular, there seems to be a lack of research into the challenging needs of the health professionals providing the abortion services, including those who do not actually administer the pills to cause a miscarriage or conduct a surgical abortion, and their clients. Clearly more attention needs to be devoted to the area of pastoral counselling in the church of health professionals and those contemplating abortion or who have one or more. This study is an attempt to contribute to this need and thus provide supportive and biblically sound counsel for both groups.

2.6 Conclusion

This chapter has reviewed key literature on abortion and has revealed the important and salient points pertaining to the termination of pregnancy on demand in South Africa. The constitution of the Republic of South Africa gives the right to women to terminate their pregnancies in the first twelve weeks should they choose that path. The operating legislation in this regard, the COTP Act, empowers the health professionals to terminate the pregnancies of the clients that demand it; andit details the procedure to be followed, including the pre-abortion and post abortion counselling for the clients. However, COTP, unlike the constitution, is quiet on the critical matter of conscientious or religious objection concerning abortion of the health professionals. This omission of an important right in COTP guaranteed by the constitution thus creates a tension among the health professionals and between them and hospital management. This study will seek to develop a pastoral intervention model to help Christian health professionals cope in this environment or face the possible major moral decision to not be involved in medical practice that includes abortion on demand. This effort is embarked upon as there is a notable deficiency in the body of knowledge in this particular area, namely, a pastoral model to address the ethical issues of health professionals and their clients seeking abortion.

The observation has been made that the debate between Christians who are pro-life and those that are pro-choice is centred around the origin of life, namely, whether life begins at conception or later. The views of theologians on these two positions are analysed in a subsequent chapter of this study. This study will seek a more normative understanding on the matter of when abortion could be biblically justified, taking into account the context of many in South Africa plagued by extreme poverty, the indifference of many men to unwanted pregnancies, and the terribly negative impact on the development of children in such situations.

The literature review on relevant empirical research with regards to termination of pregnancy has revealed a range of actual or potential negative psychological and spiritual outcomes on women who terminate their pregnancy, and also on the health professionals who perform and assist in the termination of pregnancies and for some even in after-abortion treatment when needed. No matter what the pro-choice lobby argues, it seems these effects of abortion cannot be easily avoided. The research calls for greater focus onthe complex and distressing emotional undercurrents that often flow powerfully among most involved in the termination of pregnancy arena: clients and health professionals.

[...]