Policy to practice: Translating "non-directive" pre-abortion counselling from legal stipulation to healthcare encounters.

Abstract

BackgroundThe liberalisation of abortion law does not necessarily translate into quality services. The South African Choice on Termination of Pregnancy Act includes the requirement of non-mandatory and non-directive pre-abortion counselling. However, pre-abortion counselling in public abortion clinics is often directive, coercive and, at times, anti-abortion. Objectives: We reflect on our attempts to ensure that the legislative requirement of "non-directive" pre-abortion counselling is realised in public termination of pregnancy clinics through the nurses' participation in an in-service abortion counselling certificate course (ACCC) based on person-centred and reproductive justice principles. Design: We adopted a qualitative exploratory transfer of training research design, with a goals-focused approach.MethodsUsing stratified purposive sampling, we interviewed eleven (of the 29) nurses who participated in the course about their current consultation/counselling practices and experiences. We analysed the data using template analysis, with the outcomes of the ACCC as a priori themes, supplemented by themes emerging in the analytical process. Results: Participants emphasised that their practice is now person-centred and non-directive. Non-judgmentalism, active listening, empathy, and facilitating autonomous decision-making were all listed as attributes they now bring to their pre-abortion interactions with users. These declarations were, however, interwoven with reference to contraceptive coercion and discomfort with "repeat" abortions. Providers also mentioned several institutional and systems challenges that undermined person-centred care. Conclusion: In-service training focused on non-directive, person-centred counselling, such as the ACCC, while necessary, is not sufficient to ensure that legislative or policy requirements for non-directiveness will be met. Two key elements need addressing in addition to person-centred in-service training: (1) gendered understandings of women as always having the agency to prevent pregnancies, as well as primarily responsible for contraceptive use; and (2) structural inadequacies that work against person-centredness and non-directiveness in these encounters.