Abortion services review: 10 key findings from the independent review

The final review into the State’s abortion law, three years since its introduction, has recommended some significant changes to the provision of services. Some Government Ministers are understood to be uncomfortable with the far-reaching recommendations put together by barrister Marie O’Shea. The review, seen by The Irish Times, makes 10 key findings.

1: In parts of the country, abortion services are “untenable” because of uneven geographic coverage

At present, there are 422 community providers and 11 of the 19 maternity hospitals are involved in service provision. There is uneven geographic coverage. Fewer contracts between the HSE and primary care providers are recorded in the southeast, northwest, midlands and Border counties.

The review found that in some counties, service provision is “reliant on a handful of providers across primary care and hospital settings. There is a potential risk that these staff may burnout. The service is untenable.”

The review also found that in some parts of the country, services are at risk of “ceasing altogether” were the provider to withdraw the service. One interesting recommendation to address this made by Ms O’Shea would see funding diverted, on the basis of a fixed sum per patient, from the non-providing hospital to ones providing care for women who were unable to access abortion services locally. The review also says the Department of Health should consider changing the law to expand the range of health professionals who can provide termination of pregnancy services, such as to junior doctors.

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2: Most GPs are not providing abortion care, potentially because of workload issues

The review found that is a “dearth of information relating to GPs’ reasons for not providing termination of pregnancy services” but research indicates that the main reason may be attributed to excessive workloads. A lack of hospital back up could also be a reason.

Again, the review says that allowing practice midwives and nurses and other healthcare professionals to become more involved in the provision of abortion services in the community setting could positively impact upon easing GPs’ workload burdens. Currently, the provision of abortion services is limited to medical practitioners.

3: Those who abuse conscientious objection guidelines can do so “with impunity”

The report says that there is no restriction on healthcare workers who abuse their right to conscientiously object by actively obstructing or delaying a woman’s access to care by providing misleading information. “It would appear that persons who engage in this conduct are able to do so with impunity,” the report notes.

Furthermore, the reason for some hospitals not offering services was attributed by the HSE and the Department of Health to the prevalence of conscientious objection among medical practitioners. In hospitals that do offer abortion care, issues still arise. One respondent to the research said they “witnessed colleagues being cowed into submission during meetings by colleagues who held very strong views against termination of pregnancy”.

4: Some women are experiencing delay and obstruction

Some women “have experienced delay and obstruction”, including through inaccurate and misleading information. Some have also experienced rogue agencies purporting to be pro-choice and “have felt their decision to terminate their pregnancy to be undermined”. The review says the Department of Health should consider introducing a statutory obligation on healthcare workers to refrain from providing misleading information.

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5: There is a lack of clarity around abortion where there is risk to the life or health of a woman

According to the review, medical practitioners find the wording of legislation, which allows terminations where there is a serious risk to the health or risk to the life of a woman, to be ambiguous. They said there is no guidance as to the threshold of “risk” or “serious harm”.

“The subjective nature of interpretation, together with the prospect of criminal sanction and adverse media scrutiny, risks the practice of defensive medicine, which may lead to women being denied care in Ireland,” the review says. It suggests that ministerial guidelines be devised.

6: There are similar issues around abortion in the case of fatal foetal abnormalities

The review found that there is a lack of clarity around allowing abortion in the case of fatal foetal abnormality, save in straightforward cases. “It can be difficult to implement in practice, even in cases where the condition may be fatal and associated with severe morbidity and/or disability,” the report says.

“Medical practitioners participating in this research reported that with the exception of a small number of very straightforward conditions such as anencephaly, the section (of legislation) is difficult to implement.” The review chair had strong words on this topic. “The rigid, arbitrary restriction in practice to offer terminations to women whose pregnancies are affected by complex, severe life-limiting anomalies, that might outlive the 28-day time period, by a few days or weeks, arguably is extremely unfair, particularly when it is the difference between receiving care at home and having to travel abroad.”

7: Ethical issues have emerged around palliative care

Palliative care – which is the provision of comfort care to babies born alive after termination of pregnancy – also emerged as an issue. Paediatricians and neonatologists have a key role in the provision of comfort care to newborns. “However, the extent to which they are prepared to become involved is described as differing across settings and differing across the circumstances of the birth, with some not being prepared to offer comfort care where the birth is a result of a termination of pregnancy.”

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8: The three day wait for abortion medication is problematic for women

Because of the uneven distribution and shortage of services, particularly in the southeast, northwest, midlands and Border counties, women in those areas have had travel to access GP care. The journey, the review says, can be sometimes long and come at a significant cost. The review recommends that the three day wait be made optional.

9: Criminalisation can stigmatise women and deter doctors from providing abortion services

Criminalisation of abortion can be “stigmatising for women as it reinforces its social and cultural framing as an immoral and aberrant act,” the review says. The positioning of abortion in criminal law may also “deter healthcare professionals from engaging in services, not because they do not want to provide but because they feel that the law does not protect them.” The review recommends removing the criminal sanction from healthcare workers providing abortion services.

10: Ireland’s abortion laws could be challenged under a human rights case

The report says that it appears the legal framework governing termination of pregnancy is “not aligned with Ireland’s human rights obligations”, due to the barriers around implementation. “This could lead to future challenge by women seeking terminations of pregnancy.”