Abortion: everyday problem that still cannot be discussed

The Adelaide Society is currently running a public lecture series on medical ethics and the future of healthcare in Tallaght Hospital.

One lecture was entitled Ethical Issues in Women's Health and both the lecturer, Prof Walter Prendiville, and the audience spent much of their time discussing abortion.

This was the only lecture in the series so far that was policed by security guards; and, indeed, the only lecture that most of us have attended that needed such security.

This atmosphere of menace has stalked the abortion debate in this State. It has intimidated into silence, among others, the women who have had abortions, the medical profession and the politicians.

It was noticeable at the Adelaide Society debate that some pro-life people had difficulty with contraception, believing it to encourage sexual activity.

Recent research in the North-Western Health Board area indicated, however, that young women were sexually active for over a year before they sought contraceptive advice. Whatever about abortion, contraception is no longer an issue for the majority of the sexually active population in Ireland.

But the debate on abortion remains locked into the traditional "pro-life/pro-choice" axis. It is clear that the pro-life stance is antiabortion in all circumstances.

The pro-choice group leaves it up to the individual and it has not articulated what restrictions, if any, it would like to see on abortion if it occurs in Ireland.

The "pro-life/pro-choice" debate is largely irrelevant to the women who travel for abortion. The recent crisis pregnancy study interviewed women undergoing abortions and those who did not choose abortion. Women mostly gave practical reasons for seeking abortion, such as career and job concerns, stigma of lone parenthood and financial concerns. In the crisis pregnancy study it was evident that the women knew they were engaging in an act that was ending life.

There are obvious socio-economic and educational differences between women seeking abortion and those choosing lone motherhood. More than 70 per cent of the women having abortions in the crisis pregnancy study were employed or at college. In the lone mother sample, only 40 per cent were employed, with most becoming unemployed because of their pregnancy.

The number of women who were at school was far greater in the lone mother group than in the abortion group. Those in the lone mother group were also much more likely to be in non-manual or semi-skilled jobs than those in the abortion group. Choosing to have an abortion over lone motherhood seems to be significantly more likely if the woman has access to finance and education.

In my own medical practice in a deprived area of Dublin, both teenage and unplanned pregnancies are common, with abortion scarcely mentioned by the patient. In my experience, however, the question of a possible abortion can be raised by the mothers involved. Rightly or wrongly, some take the view that the daughter's prospects of breaking the cycle of deprivation have ended with the confirmation of a teenage pregnancy.

While the limited debate about abortion continues, some 5,000 women per year travel from the Republic to Britain to have their pregnancies terminated. The figures in the crisis pregnancy report indicate that these 5,000 women discuss the problem with 8,500 partners, friends or parents.

This adds up to a total of 13,500 Irish people each year who are affected by abortion. The reality is that that debate about abortion per se is unreal; on a very practical level it is being ignored by the women themselves and by their closest friends and family.

With the number of women referring themselves for termination apparently increasing at a steady rate, it is worth asking if these women want abortion to take place in the Republic of Ireland.

The evidence from the crisis pregnancy study is not conclusive about this, although it does highlight their concern with absolute privacy. En route to Britain, women dreaded meeting anyone they might know and they would probably feel too stigmatised to undergo abortion in Ireland. It seems that once women reach the UK clinics where their plight is accepted, and they are treated courteously and competently, the sense of acceptance ends their stigmatisation.

While warnings have been issued about post-abortion depression, Dr Dermot Walsh, a senior researcher in psychiatry, has pointed out in this newspaper that the evidence does not bear this out.

It is likely in Ireland that the barriers placed in the way of women choosing abortion mean that a self-selected group of resourceful and psychologically robust women end up having abortions. It was noticeable in the crisis pregnancy study that the women did not see themselves as victims of circumstances, but in the end have made good, if difficult, decisions for themselves.

If we are seriously concerned, we need to think of reducing the numbers rather than banning abortion. Fifty per cent of our population is under 25 and this inevitably means that a lot of young people are sexually active without adequate contraception.

Young sexually active men did not associate sex with pregnancy in the crisis pregnancy study and they are hardly ever the subject of educational campaigns.

As it is, abortion is a fact of life in Ireland and we need to put in place structures that support easy access to contraception, including post-coital contraception, good clinical care of women before they travel for their termination and when they come back.

This includes having a postabortion check-up in a competent non-judgmental environment. Too often women omit this in their desire to put it all behind them. Of the 5,000 who have abortions each year, 400 of these are having their second abortion. Hence, it is important that contraception is part of the postabortion check-up.

Abortion is not going to go away. And unless policymakers take action, the trend is likely to continue upwards. The surgical termination of a pregnancy is a very challenging matter for all concerned. When I taught medicine in the United Kingdom it was noticeable that medical students with no experience of gynaecology were often blase about abortion.

When the same students had completed their gynaecology they were noticeably more reflective about it. The students I teach now have divided opinions. Most are simply for or against it and there are few shades of grey.

Meanwhile, at the end of Prof Prendiville's address, even those people who oppose abortion considered that he was courageous to have discussed the issue. But it seems very strange that one needs courage to discuss an everyday problem in a thoughtful, searching manner.

Dr Tom 0'Dowd is a general practitioner and professor of general practice at Trinity College Dublin. He was a member of the research team on the Department of Health-funded study, Crisis Pregnancy in Ireland