Professional nurses ’ attitudes towards providing termination of pregnancy services in a tertiary hospital in the North West province of South Africa

Curationis 29(1): 32-39 The Choice on Termination of Pregnancy Act (no 92 of 1996) was implemented during 1997. This study attempted to investigate professional nurses’ attitudes towards rendering termination of pregnancy (TOP) services at a tertiary hospital in the North West Province of South Africa. A quantitative descriptive research design was used to study professional nurses’ attitudes towards providing TOP services. The research results, obtained from questionnaires completed by professional nurses, indicated that most professional nurses’ attitudes included that women should be at least 16 years of age to access these services; women should not be able to access repeated TOPs; nurses would prefer to administer pills rather than to use vacuum aspirations; nurses should work in TOP services by choice only. TOP centers should have better equipment, more resources and more staff members. Nurses working in TOP services would appreciate receiving more support from their families, friends, managers and communities. Some professional nurses experienced guilt, depression, anxiety and religious conflicts as a result of providing TOP services. Despite the legalisation of TOPs, these services remained stigmatised. Professional nurses did not want to work in these services and also did not want to be associated with them.


Introduction and background information
The issue of termination of pregnancy (TOP) has been a worldwide controversy.M any societies are divided into two groups "pro-choice" and "pro-life"."Prochoice" standpoints defend w om en's rig h ts to choose w hether or not to terminate a pregnancy.The "pro-life" movement claims that a foetus is a life, and therefore TOP is tantam ount to taking a life (E veratt & B udlender, 1999:102;Reiman, 1999:9).
It has been estimated that out of 44 686 women admitted to hospitals every year with incomplete abortions, 12 842 would become ill and 425 would die due to back street abortion related complications, especially sepsis (De Pinho & Hoffman 1998:28).Nurses could help to reduce these morbidity and mortality statistics by p ro v id in g safe, effec tiv e and accessible TOP services.However, nurses who harbour negative judgmental attitudes towards women requesting TOP services, are unlikely to provide such services.Thus it was essential to study nurses' attitudes towards TOPs in order to determ ine w hether n urses' attitudes might facilitate or obstruct women's access to TOP services in the North West Province.
Nurses, being integral members of the co m m u n ities they serve, also find themselves divided into these two "pro life" or "pro-choice" groups.They come from diverse cultural and religious b ack g ro u n d s th at influence th e ir personal opinions, feelings, attitudes and p ercep tio n s w hen it com es to participating in TOP services.The study by Marais (1997:7) revealed that South African nurses' attitudes towards TOPs were not significantly influenced by their religious views.Walker's (1995:47) study also indicated that nurses working in primary health care facilities maintained that their participation in church activities did not affect their attitudes towards TOPs.However, Engelbrecht, Pelser, Ngwena and Van Rensburg (2000:6) reported that South African professional nurses experienced ethical and moral dilemmas when they had to refer patients to TO P services.Som e o f these p ro fessio n al nurses reportedly sabotaged referring pregnant women to TOP services.Nurses' views concerning the m orality or im m orality o f TOP services could be determined by their philosophical perspectives on the moral status of the foetus (Jali, 2001:30).
Ethically, nurses as caregivers are taught to preserve life.In addition, the Democratic Nursing Organisation of South Africa (DENOSA) believes that nurses have a right to freedom of choice (Poggenpoel, Myburg & Gmeiner, 1998:4).Therefore, the legalisation of TOPs by the Republic of South Africa's (RSA) government, might impose ethical and/ or moral dilemmas on nurses expected to provide TOP services.This study was done to determ ine nurses' attitudes towards providing TOP services in one referral hospital in the N orth West Hospital, offering TOP services to a large geographic area.
The World Health Organization (WHO) adheres to a strong frame of reference, which includes respect for an individual's choice regarding their personal health.The WHO (1998:1) further states that, approximately 20 million unsafe TOPs take place annually around the world resulting in 80,000 maternal deaths.Presum ably some of these maternal deaths could be avoided if legalised TOP services were provided under hygienic conditions.
According to Rau (1996:2), prior to 1975, TOPs in the RSA were only justified in circum stances where the pregnancy constituted a threat to the life of the mother.Hence there was little resistance from the "p ro -life " group.
The implementation of the CTOP Act (no 92 o f 1996) affords an opportunity to improve women's reproductive health by reducing the risk of death and disability associated with unsafe "backstreet" abortions (De Pinho & Hoffman, 1998:28).Thus nurses who provide TOP services could be regarded as helping to save these women's lives, if they adhered to the "pro choice" approach.Alternatively "pro life" protagonists could regard nurses w orking in TOP services as enabling women to abort (or kill) their unwanted foetuses.
However, the CTOP Act (no 92 of 1996) w as not accepted by some o f the professional nurses.Evidence is given in the Barometer (1997:8)  The RSA data available for legal TOPs, revealed that the Gauteng Province in the RSA, provided 48,3% of the total number of the TOPs in this country (Barometer, 1998:15).From February 1997 to January 1998,64,5% were first trimester TOPs and 35,5% second trimester TOPs.Everatt and Budlender (1999:101) revealed that 69,0% of the respondents criticised the CTOP Act (no 92 of 1996).
Professional nurses might have negative attitudes towards CTOPs, which could hamper the full implementation of CTOP Act (no 92 of 1996) in the RSA.This is reflected by the fact that, from July 2001 to July 2002 only two professional nurses were providing TOP services in the tertiary hospital, where this study was conducted, in the North West Province.Rabelo (2002:42) reported that nurses working in TOP clinics in the RSA were overworked and most of them did not want to work in these services.Despite the advent of safe legalised TOPs in South Africa, many women might fail to access these services, due to too few TOP sites and too few nurses providing these services (A lbertyn, 2002:13).Pregnant women's rights to access legal TOP services, might produce conflicts with professional nurses' obligations to preserve life.
Unless nurses are willing and able to provide TOP services, the legalisation of TOP services in South Africa cannot produce the intended benefits to the p reg n an t w om en o f this country.C onseq u en tly , it is necessary to determine professional nurses' attitudes towards providing TOP services.Based on this knowledge, programmes, can be designed to meet both the professional nurses' and the pregnant women's needs.

South Africa
In the RSA, a study conducted by Gmeiner, Van Wyk, Poggenpoel and M yburg (2001:75) showed that many nurses revealed negative attitudes and/ or ex p erien ces and suffered psychological discomfort due to the fact that they were directly involved with implementing TOP procedures.
Many communities might not accept TOPs, in many countries of the world.Marshall, Gould and Roberts (1994:568) reported that nurses in the USA lamented having to work in TOP services, and also did not approve of patients seeking these services.These attitudes among nurses continued to prevail despite the fact that TOPs were legalised in the USA during 1973(Smith 2000:78).In the RSA, where TOP services were legalised during 1996, some communities reportedly do not accept the nurses who provide TOP services.Gmeiner etal. (2001:75) reported that some nurses were victimised when it became known that they worked at clinics rendering TOP services.They were reportedly called "murderers" and "baby killers".Reportedly these nurses, as well as their families, were victimised to such an extent that these nurses had to send their children to distant boarding schools.

Support required by professional nurses providing CTOP services
The professional nurses who provide CTOP services need support from their co lleag u es, m an agem ent and communities.Providing CTOP services could involve conflicts o f interests between the profession, community, n u rs e s ' re lig io u s b eliefs, and the em ployer's expectations.The study conducted by Varkey and Fonn (1999:6) revealed that those nurses who provided TOP services in the RSA, required support due to negative feedback form their colleagues.In the study conducted by Engelbrecht et al. (2000:11) some professional nurses revealed that they sometimes felt guilty about doing TOPs and recommended that TOPs should not be w ithin the scope o f p ractice of professional nurses in the RSA.
TOPs have social and psychological implications, which could have long-term consequences for the w om en, their partners and health care providers involved with the CTOP services in the RSA (Suffla, 1997:214).Many nurses in the RSA who provided TOP services were depressed and needed someone to talk to.Some nurses stated that they kept the nature of their jobs secret from their families and some also reported that church members only knew that they were nurses (Rabelo, 2002:42) but did not know w hich type o f serv ices they provided.
Unless sufficient resources are available, CTOP services might remain ineffective in the RSA, despite legal provisions.Reportedly there are neither enough nurses nor tim e to o ffer adequate counseling services before and after TOP procedures (Engelbrecht et al., 2000:11).Professional nurses in CTOP services were overworked and only a few of them really wanted to work in the CTOP facilities in the RSA (Rabelo, 2002:42).

Research design
A quantitative, descriptive study was used to determ ine n u rses' attitudes tow ards pro v id in g TO P services.D esc rip tiv e sta tistic s, based on calculations using the MS Excel (for Windows 2000) program, were used to summarise and describe the research results obtained from questionnaires completed by professional nurses.

Population
Polit and Hungler (1997:43) describe a population as the totality o f all the subjects th at co n fo rm to a set o f specifications.The population for this study com prised all the professional nurses w orking in a tertiary public hospital in the North West Province of South A frica.The study population included all these professional nurses, whether they worked in TOP services or not.This decision was based on the fact that any professional nurse could be requested to render TOP services at any time.A total of 34 professional nurses worked at this hospital, but only 27 were w illing to participate in this study.H ow ever, two o f the 27 com pleted questionnaires contained answers only to section A (biographic aspects) of these questionnaires and had to be discarded.Thus the total number of participants in this study was 25.As all the available m em bers o f the p o p u latio n co uld participate in the study, no sample was selected for this study.The questionnaires were completed by professional nurses who could read and write English, obviating the need to translate the questionnaires (Brink, 1996: 154;Polit & Hungler, 1997:335).

Reliability and validity of the research instrument
The questionnaires were administered to professional nurses in clinics and public hospitals that did not form part of the research institution during pre-testing of the questionnaire.Ten professional nurses, working at institutions other than the hospital where the research was conducted, were requested to review, validate and verify the interpretations of the item s in the questionnaire.The questionnaires were discussed with two nurse researchers and a statistician.Their suggestions included that all complex questions should be rephrased so that every item asked one specific question only.The ten nurses, who pretested the research instrum ent, encountered no p ro b lem s in com pleting the questionnaires.They commented that the open-ended questions were time co n sum in g to com plete.
A fter consultation with the supervisors of the study, these open-ended questions were maintained as it was hoped to gather som e data about n u rse s' attitu d es towards TOPs in their own words.

Data collection process
O ne re searc h er d eliv ered the questionnaires personally and requested every professional nurse to complete the q u estio n n aire s w ithin tw o days.Appointments were made for collecting the completed questionnaires 48 hours after delivery.A total of 27 completed questionnaires were collected at the pre arranged times.

Ethical considerations
T he respondents w ere inform ed in writing and during oral communications about the nature, purpose and scope of the study.They knew that they could withdraw from participating in the study at any tim e, w ithout incurring any negative consequences whatsoever.
No nam es w ere req u ested on the questionnaire.No completed question naire could be linked to any individual, ensuring anonymity and confidentiality o f the in fo rm atio n provided.The researchers and the statistician were the only people who had access to the completed questionnaires.They were kept locked up and destroyed after the acceptance o f the research reportportraying statistics and discussions but no names of any participants.Permission to conduct the study was req uested from and granted by the relevant health care authorities of the North West Province as well as by the Research and Ethics Committee of the Department of Health Studies, University of South Africa.

Data analysis
The data were coded and entered in the Microsoft Excel program by a statistician.

Research results
Twenty-seven respondents initially took part in the research.Two questionnaires had to be d iscard ed , as these respondents did not complete any items o ther than those in S ection A (b io g rap h ical data).The research p o pulation com prised th irty -tw o professional nurses and the response rate was 78,1% (n=25).

Biographic data
In form ation was requested about participants' biographic data so that the o th er research resu lts could be contextualised against the background knowledge of who actually responded to the questionnaires, providing the data for this investigation.The respondents' ages ranged from 23 to 45 years; with 5 (20%) being older than 41 years of age; 9 (36%) ranging from 37 to 40 years of age; and only 2 (8%) being younger than 26.Out of the 25 respondents 88,0% (n=22) were Christians and no one belonged to the Muslim, Buddhist or Hindu faith in this sample; while three respondents did not indicate to which religions they belonged.Out of the 25 respondents, 12 were married, 11 had reportedly never been married, 1 was divorced and 1 was a widow.Only two (8%) of the respondents had no children.

Training received to provide TOP services
Only 4 (16%) of the 25 respondents received specific training to provide TOP services.Presumably the other 21 (84%) professional nurses did not receive such train in g .As TOP serv ices were implemented in this area during 2001 and the data were collected during 2003, it could be understood why only 3 respondents (12%) reportedly had at least two years' experience of working in TOP services.The average number of TOPs handled by the respondents' departments was 22 per month, but this monthly figure ranged from 20 to 35.In response to the question as to how many TOPs could be handled by each departm ent every month, the responses ranged from 100 to 15, but the m ajority (76% ; n=19) considered 20 TOPs per month to be a manageable number.Future research should further investigate why only an average of 22 TOPs per m onth are performed at this facility.The possibility should be explored that some pregnant women might be unable to access these services.

Professional nurses' attitudes
towards providing top services R eportedly the professional nurses' attitu d e s tow ards provid in g TOP serv ices w ere influenced by their perceptions as to which women should access these services.

Professional nurses' attitudes pertaining to patients who should access TOP services
The majority, namely 92,0% (n=23) of the professional nurses were of the opinion Community family that women who had previous TOPs should not access TOP services for subsequent unwanted pregnancies.The majority of the respondents, namely 72%, in d icated th at w om en who w ere expecting ch ildren w ith congenital abnorm alities, should be allowed to receive TOP services.
A lth o u g h the m ajo rity o f the respondents, namely 76,0% (n=19) felt that women who were raped should be given TOP services, six (24,0%) of the respondents felt that even after being raped women should not receive TOP services.However, according to the respondents, women who were victims of incest should, according to 84,0% (n=21), access TOP services.
Almost half of the sample, namely 48,0% (n=12) respondents felt that the risk of suicide should be no reason for obtaining TOP services.M ental illness in the mother, on the other hand, was seen as an indication for TOP services by 72,0% (n=18) of the respondents, also women who suffered from mental retardation should be allowed to obtain TOP services (72%; n= 18).Many respondents, namely 68,0% (n=17) were of the opinion that women with HIV/AIDS should access TOP services, should they desire to do so.
Almost all respondents (92,0%; n=23) felt that women who have no children should never be allowed to have a TOP.The resp o n d en ts w ere d ivided in th eir opinions as to whether or not women with many children (grand multiparas) should be given TOP services, as only 56,0% (n=14) of the respondents felt that TOP services should be offered to these women.
The respondents were also divided in their opinions as to w hether or not poverty should be an indication to have TO P serv ices; 52% (n= 13) o f the respondents felt that TO P services should be accessible to poor women.
Unplanned pregnancy was also seen by slightly more than half of the respondents as a reason for TOP services as 56,0% (n=14) felt that they should receive TOP services.
M ost P ro fe ssio n a l nurses who participated in this study were of the opinion that TOP services should be rendered to women who requested TOPs, but should not be rendered to women who have never had any children.They also felt that any woman should only receive one TOP in her life time, with requests for subsequent TOPs being denied.Such denials would contradict the provisions of the CTOP Act (no 92 of 1996).

Support received by professional nurses working in TOP services
The data portrayed in figure 2 indicates that professional nurses received most support from colleagues working in TOP services, colleagues not working in these services and from their spouses/partners.The Professional nurses did not perceive management to render much support to them.The need for such support was also emphasised by a study conducted by Poggenpoel et al. (1998:4) revealing that the majority of nurses did not want to work in TOP services, and that if they were forced to do so, they would leave the nursing p ro fessio n ra th e r than provide TOP services.

CTOP Act
In response to the question as to whether a copy of the CTOP Act was available in their hospital, the majority (56,0% n=14) of the respondents indicated that the institution had such a copy, whereas 20,0% (n=5) did not know and 24,0% (n=6) indicated that their institution did not have a copy of the CTOP Act (No 92 of 19%).Many of the respondents, namely 72,0% (n=18) felt that they needed to read the Act often as they did not know it well enough.The majority, namely 80,0% (n=20) of the respondents indicated that they read the Act less often than once every three months.Approximately half o f the re sp o n d en ts (56,0% ; n=14) indicated that the Act was acceptable and did not need to be rev ised .T hose respondents who disagreed indicated that the Act should be amended to allow only women aged 16 or older to access TOP services.
W hile m ost re sp o n d en ts w ere

Respondents' attitudes towards TOP clients' gestation ages
To determine at what gestation age TOPS should be done, the respondents had to respond to a number of statements.Some resp o n d en ts nam ely 44,0% (n= 11) indicated that they believed that all patients who received TOP services were less than 16 weeks pregnant.Only 12,0% (n=3) of the respondents indicated that they believed that 50-80% of the patients were within their second trimester of pregnancy.
Only 20,0% (n=5) of the respondents felt that some patients were too advanced (beyond 20 weeks) in their pregnancies to receive TOP services, but they believed that this was no more than 5,0-10,0% of the TOP clients.

Respondents' opinions about nurses who usually render TOP services
Respondents were requested to indicate how strongly they agreed with each given statem ent.H owever, not all respondents answered all the questions.
The following findings are presented in table 1.
Some of the professional nurses (36,0%; n=9) agreed that generally nurses refused to render TOP services and only 8,0% (n=2) strongly disagreed that nurses generally refused to render TOP services.
Two respondents (8,0%) strongly agreed that nurses should be penalised for refusing to render TOP services and 36,0% (n=9) disagreed while 52,0% (n= 13) stro n g ly d isag reed , reg ard less o f offences and penalties stated in the CTOP Act (no 92 of 1996:8) should any person obstruct access to TOP services.Some professional nurses (32,0%; n=8) agreed that nurses who rendered TOP services were generally caring people.Of the professional nurses 56,0% (n= 14) strongly disagreed with the statement that nurses who rendered TOP services were unfriendly.Only 50,0% (n=10) of the resp o n d en ts agreed that TOP patients were monitored hourly.This asp ect m ight require serious reconsideration, as the monitoring of TOP clients might be inadequate, based on these responses.E ven although only 14,0% (n=10) disagreed with the statement that nurses generally leave their TOP patients to care for themselves, this could indicate that some patients did not receive adequate nursing care while undergoing TOP procedures.This potential lack of nursing care provided to TOP patients, might be attributable to South African nurses' dislikes for working in TOP services as reported by a number of previous research reports (Engelbrecht et al., 2000:13;Gmeiner et al., 2001:73;Poggenpoel et al., 1998:5).
No resp o n d en ts agreed w ith the statem ent that nurses generally left patients to clean up after the pregnancies had been terminated; while 60,0% (n=15) strongly disagreed.
M ore than half of the respondents, namely 52,0% (n=13), strongly agreed with the statement that they should work in TOP services out of choice only.The majority of the respondents indicated that they strongly agreed (36%; n=9) with the statem en t that the attitu d es o f the community influenced their attitudes toward TOPs and 24% (n=6) agreed, whereas 8% (n=2) strongly disagreed and 32% (n=8) disagreed.The majority of the respondents strongly agreed (36%; n=9) that the attitu d e o f th eir fam ilies influenced their attitudes toward TOPs and 32% (n=8) agreed with this statement, whereas 4% (n=2) strongly disagreed and 37 Curationis March 2006 24% (n=6) disagreed.Some respondents (24%; =6) strongly agreed that the attitudes of their friends/ colleagues influenced their attitudes • toward TOPs, and 36% (n=9) agreed.Twenty percent (n=5) of the respondents strongly disagreed and 20% (n=5) agreed with the statement pertaining to their friends/colleagues' attitudes.
The aspect th at had the greatest in flu en ce on the attitu d e s o f the respondents toward TOPs was religion as 56% (n=14) o f the respondents indicated that they strongly agreed that religion influenced their attitudes toward TOPs and 16% (n=4) agreed, whereas only 4% (n=l) strongly disagreed and 24% (n=6) disagreed.This finding concurred with the standpoint of Downs (2005:49) that theological science has a very simple conception of man, namely th at " ... as soon as he has been conceived, a man is a man (with a soul)".Nurses who adhere to these religious perceptions would regard any TOP as • destroying a soul -possibly accounting for the great religious influence on nurses' attitudes towards TOPs.

Conclusions
The study revealed that nurses would prefer to work in TOP services out of their • own free will, and not feel coerced to work there, nor fear retaliation should they refuse to do so.The training of nurses • about CTOP issues was apparently inadequate.TOP services were still stigmatised and something needs to be done by the G o v ernm ent and the Department of Health to de-stigmatise TOP services.The study also revealed a lack of support for nurses who rendered TOP services.
The CTOP Act (no 92 of 1996) affords women an opportunity to reduce risks of death and disability associated with back street abortions (De Pinho & Hoffman, 1998:28).Unless women can access TOP services, and unless nurses are willing and able to provide these services, mortalities and morbidities attributable to back street abortions, will persist despite the legalisation of TOPs in this country.

Limitations of the study
Limitations that were identified during the course of the study included that:

Figure 1
Figure 1 Professional nurses' opinions about who should not received TOP services (n-25; 92% = 23 out of 25 respondents

Figure 2
Figure 2 Support professional nurses received from various people (figures indicated on top of columns indicate the percentage of responses out of a total of 25)

Table 1 Attitudes towards TOP services (part 1)
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