Accelerating the Pace of Progress in South Africa: An Evaluation of the Impact of Values Clarification Workshops on Termination of Pregnancy Access in Limpopo Province

Executive Summary

Although legal barriers to safe abortion in South Africa were lifted in 1996 after years of struggle, pervasive misunderstanding of the abortion law persists. Ipas South Africa collaborated with the Women's Health Directorate of the Limpopo Department of Health and Welfare (DoH) to create a provincial strategy for expanding and increasing access to termination of pregnancy (TOP) services for women who need them. Together, Ipas and the Limpopo DoH conducted 22 values clarification (VC) workshops for approximately 645 community members and health-care providers in the province in 2002 and 2003. The workshops were designed to encourage attitudes and behaviours that favour the protection of women’s reproductive rights at the community level and greater compliance with the Choice on Termination of Pregnancy (CTOP) Act at the health-facility level.

This study employed a retrospective multi-method design to assess the impact of the workshops at the individual, community and facility levels. Qualitative and quantitative assessments of personal transformation were collected from 193 workshop attendees. Knowledge, attitudinal and behavioural indicators of change were measured. To gauge the impact of the workshops on the type and quantity of services offered, site visits were conducted in 20 hospitals and clinics before and after the intervention.

Findings were:

• Participants found the workshops to be a helpful forum in which to consider diverse viewpoints. Participants overwhelmingly reported a positive, respectful climate; 97.4% perceived that everyone attending the workshops had an equal opportunity to speak and be heard.
• Four out of five workshop participants demonstrated a firm grasp of the main elements of the CTOP Act; however, critical gaps still exist in their knowledge of the legal right to second-trimester abortion. Many participants were still unaware of the disparities in reproductive health that exist between Limpopo and other provinces.
• Among the workshop participants, 48% reported that they were either generally or very supportive of TOP services prior to the advent of the workshops. Only 26% described themselves as initially opposed to TOP. This suggests that half of the recruited participants were favourably disposed to the issue before the workshop began.
• There were few statistical differences in attitudinal or behavioural outcomes between those who reported prior opposition to TOP and those who voiced prior support. Most participants reported increased empathy, support and comfort regarding TOP service delivery.
• Demonstration of manual vacuum aspiration (MVA) instruments was identified as a critical component of the workshop experience. Facilitators and participants reported that the demonstrations helped to dispel myths and misperceptions about the MVA procedure, which were root causes of some participants’ fears and apprehensions about TOP.
• Most attendees (52.4%) surveyed reported that they had pursued a follow-up action as a consequence of the VC workshops. Over a third had further contact with the facilitators. One in five (21.9%) attended a subsequent meeting on issues identified in the workshops.
• Values clarification can motivate health workers to want to become trained TOP providers. Of the eligible nurses and midwives who lacked training in TOP prior to the workshops, all 10 (100%) reported a desire to be trained as TOP providers following the workshops.
• Values clarification, provider training and equipment provision do not automatically lead to widespread inauguration of new TOP services in the medium term. Only two out of eight designatedbut-off-line hospitals began to offer services following the intervention. However 36 letters requesting designation for TOP services were sent into the National Department of Health, all requests were granted in December 2004.
• The VC workshops coincided in time with increased service delivery in low-functioning as well as well-established TOP facilities. Seven out of 10 facilities increased TOP service delivery over the 2003–2004 study period. The mean number of TOP services performed in a 90-day period more than doubled, increasing from 67 (±45) to 134 (±72) cases.
• Although 89.6% of nurses and midwives were “very comfortable” with the provision of TOP services within their facility and as part of their job responsibilities, over half reported discomfort with providing non-judgmental care to women who need repeat abortions. A third reported discomfort with second-trimester services. Further research is needed to understand healthworker beliefs and needs in terms of service provision. There is also an indication that although services are being provided the providers have conflicting feelings regarding some of the more sensitive aspects of service provision. More emotional and psychological support may be needed to promote the non-judgemental approach to providing services.

This study offers encouraging findings about the impact of values clarification at the community, facility and individual levels, as well as providing important insight about enhancing the model to ensure the desired outcomes.