Conscientious objection and its impact on abortion service provision in South Africa: a qualitative study

Background: Despite abortion being legally available in South Africa after a change in legislation in 1996, barriers to accessing safe abortion services continue to exist. These barriers include provider opposition to abortion often on the grounds of religious or moral beliefs including the unregulated practice of conscientious objection. Few studies have explored how providers in South Africa make sense of, or understand, conscientious objection in terms of refusing to provide abortion care services and the consequent impact on abortion access. Methods: A qualitative approach was used which included 48 in-depth interviews with a purposively selected population of abortion related health service providers, managers and policy influentials in the Western Cape Province, South Africa. Data were analyzed using a thematic analysis approach. Results: The ways in which conscientious objection was interpreted and practiced, and its impact on abortion service provision was explored. In most public sector facilities there was a general lack of understanding concerning the circumstances in which health care providers were entitled to invoke their right to refuse to provide, or assist in abortion services. Providers seemed to have poor understandings of how conscientious objection was to be implemented, but were also constrained in that there were few guidelines or systems in place to guide them in the process. Conclusions: Exploring the ways in which conscientious objection was interpreted and applied by differing levels of health care workers in relation to abortion provision raised multiple and contradictory issues. From providers' accounts it was often difficult to distinguish what constituted confusion with regards to the specifics of how conscientious objection was to be implemented in terms of the Choice on Termination of Pregnancy Act, and what was refusal of abortion care based on opposition to abortion in general. In order to disentangle what is resistance to abortion provision in general, and what is conscientious objection on religious or moral grounds, clear guidelines need to be provided including what measures need to be undertaken in order to lodge one's right to conscientious objection. This would facilitate long term contingency plans for overall abortion service provision.