With just three weeks to go before the planned introduction of abortion in Ireland, there remains widespread scepticism among health professionals that the deadline of January 1st will be met. The legislation to give effect to the measure still has to complete its passage through the Oireachtas and questions about resources and supports have still to be fully answered. The thorny issue of conscientious objection also looms large for many doctors, nurses and pharmacists, and existing Medical Council ethical guidelines governing the medical profession will not be revised in time for the deadline.
Notwithstanding these considerable doubts, the Government and in particular Minister for Health Simon Harris has made the provision of abortion by the start of next month an absolute priority. At this point, it therefore seems likely the service will begin as planned in the New Year.
Dr Peter Boylan, the former master of the National Maternity Hospital who has been tasked by the Government with organising the new service, has said abortion will be available "in some form" in all the State's 19 maternity units from January, and also in the community through GP practices.
He has, however, also warned “there will be problems and nobody should expect perfection” at the start.
Despite the last-minute nature of the arrangements, the broad outline of how the service will operate is slowly becoming apparent. Knowledge gaps remain and these will probably not be filled in until after the Oireachtas passes the Health (Regulation of Termination of Pregnancy) Bill and full sets of clinical guidelines are published, but it is now possible to sketch out the mechanics of how an abortion service will be provided in Ireland for the first time.
So when will abortion become legal in Ireland?
Abortion has been legal in specified circumstances, such as a threat to the life of the mother, for many years but the Government's plan to allow terminations generally in the first 12 weeks of gestation is due to come into force on January 1st.
Because of the Christmas/New Year break and the three-day cooling-off rule that will apply to a woman seeking a termination, it is likely to be the second week of January before the first abortions take place under the new system.
Who will be entitled to a termination?
From next month, abortion will be available on request up to the 12th week of pregnancy. This is dated from the first day of a woman’s last menstrual period.
Thereafter, abortion will be available where there is a risk to a woman’s life or a risk of serious harm to the health of the mother. Certification will be provided by two doctors, one an obstetrician, and the foetus must not have reached viability.
Terminations will also be permitted in cases of fatal foetal abnormality, where is it considered the foetus will die within a month of birth.
Early medical abortion, up to the first nine weeks, will be available in primary care, mostly in GPs' surgeries, but also in specialist clinics such as those run by the Irish Family Planning Association. Abortions from nine weeks on will take place in hospital maternity units.
So how will a woman who wants a termination get one?
The main access to the service will be via a 24-hour “My Options” helpline. The woman will be able to choose from three options: access to non-directive counselling; information on how to access services; or clinical triage of complications. If she is seeking a termination, she will be directed to a provider who has opted in to the service.
In situations where a woman goes to a GP surgery seeking a termination, the GP will provide the service if he or she has opted in, or else refer the woman to another provider or to the helpline.
Opted in? What does that mean?
Only those doctors (or other health professionals) who wish to provide the service will do so, whether in a hospital or community setting. Women who seek a termination through the helpline will be referred to GPs who have opted in, or to a hospital maternity unit where they will be dealt with by staff who have opted in.
So doctors will be able to refuse to have anything to do with the service?
No. The right to conscientious objection is recognised but, in accordance with existing Medical Council guidelines, a doctor who refuses to treat a woman seeking an abortion may still have to transfer care to a colleague who will meet her needs. In the words of the legislation, which applies to all medical professionals, “a person who has a conscientious objection shall, as soon as may be, make such arrangements for the transfer of care of the pregnant woman concerned as may be necessary to enable the woman to avail of the termination of pregnancy concerned”.
Can the woman get a termination immediately?
No. A three-day cooling-off period must elapse between the initial assessment and the termination to ensure a fully considered decision.
Then what happens?
Guidelines have yet to be published outlining exactly what will happen. Once the woman has given informed consent and her medical history is assessed, the abortion pill, a combination of two medications, will be prescribed. Mifepristone ends the pregnancy by blocking the hormone progesterone. Misoprostol makes the womb contract and induces the loss of the pregnancy, similar to a miscarriage.
If the woman is under nine weeks pregnant, she will take the first tablet after the three-day cooling-off period, probably in the GP’s surgery. She will be given the second tablet to take one to two days later. Misoprostol causes cramps and heavy bleeding.
Terminations over nine weeks will take place in a hospital, where the administration of the two drugs will be staggered over one to two days while the patient is clinically monitored.
Most abortions will be medical (using pills). If a woman requires a surgical termination after the cooling-off period, she will present to the maternity unit for the procedure.
What about complications?
One-in-10 women who take the abortion pill seek medical attention, research from other countries shows. Those who contact the helpline may be referred to hospital for gynaecological care. Excessive bleeding can occur in one in every 1,000 terminations but the absence of bleeding can also be problematic, as it may indicate an ectopic pregnancy. The abortion pill does not terminate an ectopic pregnancy which occurs outside the womb.
How will a woman know the abortion pill has worked?
Reduced bleeding and cramping usually indicates the pregnancy has ended. The continuation of pregnancy, and the risk of some tissue from the pregnancy remaining in the womb, is possible, but not probable, after a medical abortion. If there were any doubts, the woman’s medical practitioner would refer her for an ultrasound scan.
Detailed patient information leaflets will be provided in advance of any procedure.
How much will the service cost?
Abortions will be provided free, whether in a community or hospital setting. GPs are to be paid a fee of €450 for the three patient visits envisaged as part of the service.