Abortion in Ireland: Four weeks in, how’s it working?

Next week will mark one month since the introduction of general abortion services for the first time in the history of the Irish State. In the final weeks of 2018, there were dire warnings from senior medics and family doctors that the January 1st deadline was being “rushed” and was “dangerously unrealistic”.

Only nine maternity hospitals were ready to provide full access to abortion care, with the remaining 10 expected to come on board shortly. Some 240 general practitioners have now signed up to the service. Despite the less than comprehensive level of access, abortions are now happening across the country in hospitals and in general practices.

But in the short time since the enactment of the law, some serious concerns have emerged.

For many women, their first experience of the new system will be through the HSE’s MyOptions helpline, which offers information on the location of doctors providing abortion care, as well as access to counselling and aftercare.

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Helen Deely, who leads the HSE Sexual Health and Crisis Pregnancy Programme, says there were 500 calls made to the helpline in the first week.

“It looks as if it is settling down, so we are now looking at an average of 55 to 60 calls a day coming in,” she says. The calls are mainly a mix of women seeking access to an abortion and healthcare professionals looking for advice on the new service.

“Primarily women are ringing seeking information around where they can access abortion services in Ireland, so they are looking for contact details of GPs providing the service,” says Deely.

“Equally, women are ringing seeking counselling and someone to talk to. There is also a 24/7 nursing line giving out information for women who are going through an abortion. If a woman has any concerns or is experiencing any side-effects she can be put through to a nurse.”

There were some concerns that anti-abortion activists would target the helpline to find out which doctors were offering the service. These fears have been borne out.

“It appears people were ringing seeking GPs’ information locally. The thing about the helpline is it has to take everyone at face value and trust everyone through the process. So they have no way of knowing; they can only trust what people say to them over the phone.”

As a result, a number of protests have sprung up in Galway, Kilkenny and Louth.

Protesters have no way of discriminating between which patients are attending for routine check-ups and which women are suffering a crisis pregnancy, given the fact that women can access the abortion pill up until nine weeks’ gestation at a GP clinic.

You can't rush people in circumstances where they are in a crisis pregnancy

Nick Breen is a GP and a senior clinical lecturer in general practice at UCD. He has yet to sign up to to provide abortion care, but anticipates that he will do so after he takes part in a training course and after he consults with his practice colleagues.

He supports the call for a new law that would create a no-protest buffer zone around clinics. “I do agree with that concept of exclusion zones. I don’t think someone should be allowed to put up a barrier in any way to prevent people from accessing healthcare services.”

‘Not able to cope’

Resourcing is among GPs’ biggest concerns about the new service, he says. “I know GPs who signed up to the service and had their names on the MyOptions helpline. They . . . were overloaded with patients.” Those doctors withdrew their name from the MyOptions public list because they were “not able to cope with the demand”, Dr Breen says.

“We have to acknowledge the reality. Each of these consultations is detailed and prolonged. People have reasons to attend for abortion services that require a proper assessment; they are not in and out. You can’t rush people in circumstances where they are in a crisis pregnancy.”

Between nine and 12 weeks’ gestation, a woman who needs to access a termination can do so in a hospital setting.

Prof Fergal Malone, Master of the Rotunda Hospital, says his hospital was one of the first maternity units to sign up to provide the services. Since the start of the month, the hospital has provided abortion care in all scenarios, he says.

“The hospital is providing a full range of services. Terminations are happening in all three categories. Namely: patients under 12 weeks who choose to have a termination for their own reasons; patients who are using termination of pregnancy for fatal foetal abnormalities; and patients having a termination for serious maternal health problems.”

The most serious concerns are emerging in the first group.

The Rotunda has had to curtail its services so that abortions will not be allowed for women at more than 11 weeks’ gestation – instead of the intended 12 weeks – because a procedure can take several days to complete, and the obstetricians fear they will fall foul of the law if the 12-week period is breached.

‘Considerable ambiguity’

“The reason the 12-week group is causing a challenge is because the legislation is written with an upper limit of 12 weeks and zero days. But there is considerable ambiguity as to whether 12 weeks means the date at which the termination starts, or the date at which the termination ends.

Given there is a potential 14-year jail term for getting this wrong, you can understand why doctors are seeking absolute certainty and clarity

“Some people rather simplistically see a termination as occurring at a single moment in time, and while that might be true for surgical procedures, for medical procedures the duration of the termination of pregnancy can span many days.”

Prof Malone says that when the three-day waiting period is factored in, along with the time it takes for the medication to run its course, this could push the timeframe beyond what has been legislated for. Because the law contains criminal sanctions, anxiety is growing among doctors.

“There have been some letters written by the Chief Medical Officer’s office, saying that – and I quote – ‘in some cases it may be reasonable to continue past the 12 weeks, zero days’. The letter does not specify what those ‘some cases’ are.” Prof Malone says further clarity has not been offered on this point – though he has sought it.

“Given there is a potential 14-year jail term for getting this wrong, you can understand why doctors are seeking absolute certainty and clarity on this matter. [These have] not been forthcoming from the Chief Medical Officer’s office or indeed the HSE.”

Prof Malone says the Institute of Obstetricians and Gynaecologists wrote recently to all obstetricians on this point, stating the situation is still ambiguous.

“The people at the coalface aren’t HSE administrators, they aren’t Department of Health leaders, they are actually the doctors. The actual person who is potentially at risk of going to jail is the doctor.

“As the CEO of the Rotunda Hospital, I have an obligation to care for patients but I also have an obligation to care for my staff. I can’t put my staff in danger where if there is ambiguity.”

Do we really believe that no woman has the ability to process complex medical information in an hour?

Part of the problem appears to be the three-day waiting period. Fianna Fáil TD Billy Kelleher previously claimed in the Dáil that this provision was only inserted into the law to allay the concerns of the Tánaiste, Simon Coveney.

“I don’t know of any other surgical or medical procedure where a patient is forced to wait three days before they are allowed make a decision. It is somewhat, you could argue, paternalistic,” Prof Malone says.

“Do we really believe that no woman has the ability to process complex medical information in an hour?”

Helen Deely says the HSE is monitoring the helpline to determine whether the three-day wait is proving problematic.

“It is important that we now monitor [this]. That is the key piece we would like to ensure happens from here on in. We would like to see if three-day wait is having any impact or causing any blocks.”

Prof Malone says the threat of criminalisation is also having a “chilling” effect on doctors who already face sanction for any potential wrongdoing through the Medical Council.

The second group referred to by the professor are women who seek a termination after the diagnosis of a fatal foetal abnormality.

Last week in the Dáil, two TDs raised the case of a woman who they said had been diagnosed with a case of fatal foetal abnormality, and who had been denied an abortion despite this fact. Solidarity TD Ruth Coppinger also referred to the “chilling effect” of criminalisation as a possible reason for what had happened.

In a letter to the woman, the Coombe Hospital said the anomaly was complex, but not fatal. People Before Profit TD Bríd Smith said the woman had told her that “this is not what I voted for”.

The law states that a termination can be carried out if there exists an anomaly that is likely to lead to the death of the foetus either before or within 28 days of birth.

No one can predict that any individual baby will die at a certain time. Nobody has the ability to do that

Prof Malone says he does not believe that doctors are worried about making the wrong call in this regard.

“We’ve faced complex foetal abnormalities for many years at the Rotunda. We are used to presenting cases of complex foetal problems and discussing them as a group.

“No one can predict that any individual baby will die at a certain time. Nobody has the ability to do that, so that is why I believe the legislation is written in terms of the opinions being formed in good faith.”

Conscientious objection

A further complication that has presented itself, in both a hospital setting and in general practice, is in the area of conscientious objection.

Dr Breen says many GPs who are conscientious objectors are planning to attend training sessions despite the fact they have indicated they will not provide the service.

He says many doctors “feel they need to know about what’s going on so they can answer questions” if asked by a patient.

In the Rotunda, the issue presents a serious logistical challenge.

“I have written to all of the members of Rotunda to let them know that the Rotunda respects our staff’s right to have their own personal beliefs. We will stand by that,” said Prof Malone.

“We would never force a staff member to participate in a surgical procedure, but conscientious objection doesn’t then extend to booking the patient into the hospital or recovering the patient post-operation. Conscientious objection can only relate to aspects of a procedure that a staff member may be directly involved with.

“From a management perspective, it is very difficult to run the service because if I have a patient scheduled tomorrow to come in for a termination, I can’t just look up a list of my staff to see if they are conscientious objectors or not. I would have to delve a bit deeper and say, is that staff member a conscientious objector to all terminations of pregnancy, or certain aspects?

“To be absolutely honest, a lot of staff are evolving in their thinking, and they are not exactly sure how they feel about this.”

Minister for Health Simon Harris has committed to reviewing the law in three years. But on the evidence of the first month, he may have to address some emerging issues much sooner.

Speaking to The Irish Times, the Minister says Ireland has come "a very long way in the last month". "I always said, the Government always said, and indeed the health care professionals involved in rolling out the services said it would take time to evolve.

“The fact that there have been women in Ireland for the last month able to pick up the telephone, talk to a trained professional, hear all of their options, of which abortion is one, be given advice, is something that was not possible in our country only weeks ago.”

“We have come a very long way in the last month. The number of GPs wanting to provide the service is increasing. We have two of our major national maternity hospitals, Holles Street and the Rotunda, providing the services and now the Coombe is ready to come on board in the coming days.”

In relation to the ambiguity around the 12 week limit raised by Prof Malone, Harris says: “The law is the law ... It was debated extensively throughout the referendum campaign and throughout the passage of the legislation. One would hope and expect as services become embedded and normalised by the health service, women can access these services at an earlier stage in their pregnancy.”

On the three day wait, Harris says: “I think we are only about four weeks in to the provision of the service. We need to let the services evolve. I did put into legislation that there would be a full review in three years and I think how the act operates can be looked at in that context. Legislators have the powers to keep all issues under review but I really believe, and I believe is passionately, there was on onus on us to do what we said we would do.”