Abortions demand best of medical care

MEDICAL MATTERS:LAST WEEK'S ruling by the European Court of Human Rights in the case of ABC v Ireland has implications for medical practice here.

The judges found unanimously in favour of applicant C, who had become pregnant while in remission for a rare form of cancer. But the court judgment said the principle underpinning Ireland’s abortion law does not violate the European Convention on Human Rights. This principle provides that a pregnancy may be terminated only where it poses a substantial risk to a woman’s life.

However, in the C case, the judges decided the procedures that require a woman to apply to court and/or consult with a doctor to determine if she is entitled to a termination of her pregnancy are deficient. It implies that C experienced difficulty accessing primary care or specialist care.

However, a 2004 study found that 36 per cent of Irish GPs had seen a woman with a crisis pregnancy in the previous month. Some 93 per cent of GPs routinely provide crisis pregnancy counselling.

Post-abortion care of women who have travelled abroad for a termination is part of routine medical care provided by almost all GPs in the Republic. Regardless of which method of abortion is used, it remains a medical procedure; as such it carries with it the risk of complications.

The Crisis Pregnancy Agency and the Irish College of General Practitioners have published joint guidelines for doctors providing care to women post abortion.

There are broadly two types of termination of pregnancy: medical and surgical. The indications for each largely depend on the length of the pregnancy. Other factors include the preference of the woman; the facilities available; and the training of the doctor.

Early medical abortion (up to nine weeks) involves the use of drugs to cause a miscarriage. Mifepristone blocks the action of the hormone that makes the lining of the womb hold onto the fertilised egg. Misoprostol, given 48 hours later, causes the womb to contract. The lining of the womb breaks down and the embryo is discharged as bleeding takes place. Early medical abortion does not require an anaesthetic.

Vacuum aspiration is used from five to 15 weeks of pregnancy and involves a suctioning of the womb. A thin plastic tube is inserted through the neck of the womb and an electric vacuum applied or a hand-held plastic syringe used to evacuate the uterine contents. A local or general anaesthetic is used.

From 13 to 22 weeks of pregnancy, surgical dilatation and evacuation is the preferred surgical method. Unlike DC, which includes the use of a sharp instrument to scrape out the lining of the womb, DE means the contents are evacuated in a less invasive way. The procedure usually involves a general anaesthetic and an overnight stay.

The most common complication following termination is infection of the genital tract. It may occur in up to 10 per cent of cases and so prophylactic antibiotics are often prescribed. Part of the placenta or foetal tissue may be retained after an abortion, leading to persistent or heavy vaginal bleeding after the procedure. The later the abortion, the greater the risk of side effects; the rate of complications is 3-5 per cent after 12 weeks gestation.

Psychiatrists are divided on the psychology issues surrounding abortion.

A study published in the British Journal of Psychiatry in 2008 found that women who had abortions had higher rates of mental health problems. The conditions most associated with abortion included anxiety and substance use disorders.

However, research by Prof David Ferguson and colleagues from the University of Otago, New Zealand, concluded the overall effects of abortion on mental health were small. Researchers estimated that exposure to abortion accounted for 1.5-5.5 per cent of the overall rate of mental disorder in the group of women studied.

The latest European ruling means doctors and their professional organisations must re-examine the issue of accessibility of medical care for women with crisis pregnancies.

mhouston@irishtimes.com