The 100th day of Ireland’s new abortion service was marked last Thursday in the same way as all the previous days – by a conspicuous lack of comment.
If you haven’t heard much about the service since it was introduced last January 1st – and an awful lot less than was heard about abortion this time last year – it is because most of those providing terminations are keeping their heads down.
“No one wants to draw attention to the service, but just to let it quietly move along,” says one source, summarising the views of medics in one of Dublin’s maternity hospitals.
The provision of terminations under the new arrangements is decidedly patchy, with barely one-tenth of GPs and half of hospital maternity units participating
Little official information is available about the service – how many women are using it, how far are they having to travel for a termination, what ethical and medical issues are arising. Doctors interviewed for this article generally paint a picture of a service that is bedding in steadily despite a few hiccups along the way.
“We’re satisfied we’ve made a steady start. There were complaints at the start but they’re at a low level now,” says a HSE spokesman.
Most doctors say demand is lower than they expected, suggesting women too are responding cautiously to the service, especially when it is provided locally.
The provision of terminations under the new arrangements is decidedly patchy, with barely one-tenth of GPs and half of hospital maternity units participating.
Initial problems with referral pathways have been ironed out, but the provision of blood tests for some women is still an issue.
Despite these shortcomings the prevailing view is that there is no going back.
“The decision has been made. The ship has sailed,” says one GP, who is personally opposed to abortion. “And I’m not going to block it.”
“The horse has bolted,” agrees Tallaght GP Prof Tom O’Dowd, one of the 307 doctors who have signed up to provide medical abortions in their surgeries.
Referral rate
It will be the middle of 2020 before official figures are published on the numbers using the service. The Start group of GPs, which has trained many doctors to deliver the service, says its 240 members dealt with 900 women to the end of February.
The referral rate to hospital is less than 10 per cent, according to Start member Dr Mike Thompson. Busier doctors in Dublin are said to be dealing with up to six women a week.
Yet outside the cities demand is low. Some say it is a lack of choice: there are, for example, “one or two” GPs offering terminations in Co Mayo, and about three in Co Tipperary, according to locals.
A GP in the west says neither he, who is not offering the service, nor his business partner, who is, have had many queries. “They’d rather go to Dublin or even England than come here or go to the local hospital, where half the county might know their business.”
"Some women are choosing to go to a GP in the city, perhaps because of the perceived stigma," says Sinead Magner of Tipp for Choice. "They're travelling of their own volition."
Magner says rural pro-choice activists feel “disregarded” by the way the service has rolled out. “Three GPs in all of Tipperary isn’t enough; after all, we voted Yes by 59 per cent.”
Criticising the lack of rural perspective in the planning of the service, she points out the three-day cooling off period that applies before a termination can be carried out can entail long travel times, twice over, for women living in remote areas.
Double figures
Dr Cliona Murphy, chairwoman of the Institute of Obstetricians, estimates the number of abortions carried out in each of the Dublin maternity hospitals so far as being "in double figures". Some GPs perform more terminations in their surgeries than any obstetrician in a hospital, she reckons.
Under the legislation GPs can carry out terminations up to nine weeks, while terminations between nine and 12 weeks are performed in hospitals. After 12 weeks abortion is allowed only in certain specific circumstances.
“I thought I would see a lot more women coming into the hospitals, but the MyOptions [telephone helpline] has worked well, and those GPs who are providing the service have been fantastic in stepping up to the mark.”
A majority of women presenting with fatal foetal anomalies have opted to terminate their pregnancies, she notes, showing that “Irish women are not that different from women in other countries”.
Other women have opted not to proceed with an abortion, even after referral to hospital, according to the HSE spokesman.
There have been protests, of course, from the daubing of a GP surgery in Longford with graffiti to pickets or silent vigils across the country.
“I expected more. Mostly it’s been a lot of old men and women, wizened old feckers reciting the rosary outside surgeries,” says O’Dowd [himself retired from TCD].
He credits the intervention of Archbishop of Dublin Diarmuid Martin, who urged caution on anti-abortion protests, with “taking the vehemence out of the pro-life thing”.
While some hospitals have been targeted for protests by anti-abortion groups, Dr Murphy says the fact hospitals are used by women for a wide variety of different reasons had made such protests more difficult.
She says she is satisfied hospitals have taken sufficient measures to protect the confidentiality of patients.
But if everything is going so well why are more than 3,000 of Ireland’s GPs, and nine maternity units, not offering the service?
Spectrum of opinions
The answer lies in a mix of caution, inertia, demographics and downright opposition.
The spectrum of opinions on the new service was always more crowded than might have been indicated by the heated debate between the anti-abortion and pro-choice lobbies.
A sizable group of doctors argued the health service was not ready for the January 1st deadline. Guidelines and patient referral pathways were not in place, and resources were lacking, they said.
Minister for Health Simon Harris and his advisers rebuffed this opposition, guidelines were cobbled together, and the deadline was met. Even so, it took over a month for one of the big Dublin hospitals, the Coombe, to begin offering terminations.
That debate is dead now. "Although it would have been better to have had national guidelines and resources in place before commencing the service, it is now up and running," says Prof Chris Fitzpatrick, former Coombe master and one of those who felt the measure was rushed.
“Most importantly, we are providing compassionate care for women who a few months ago would have had to leave the country. The Minister staked his political reputation on introducing this service, and deserves considerable credit for what has been achieved.”
Many older doctors have not gone to the bother of training for a new service; in rural areas the handsome €450 fee won't count for much if you've only a trickle of customers
In the community many GPs have adopted a “wait and see” approach. More than 500 have received training so there are several hundred doctors who are trained but have yet to opt in to providing the service.
Many older doctors have not gone to the bother of training up for a new service at this stage of their careers; in rural areas the handsome €450 fee won’t count for much if you’ve only a trickle of customers.
O’Dowd says some of the doctors he trained with are not involved because they are “brassed off” with the Government.
“They were put off by the enthusiasms of both sides; some saw the pro-choice groups as patsies of the Minister. Ethics didn’t come into it. A lot of GPs are under significant pressure.”
Antagonism
The new GP contract negotiated with the Irish Medical Organisation, which has been well received by the profession, may dissolve much of this antagonism, he thinks.
Dublin city centre GP Keith Perdue is pleased the Eighth Amendment has been repealed but is not yet offering terminations.
“We are not yet ready as a practice because I have yet to do the necessary training, and some of my colleagues have ethical reservations, which, of course, will be respected.”
Women in Dublin have other options, he says. “More women’s lives are at risk right now by being on a trolley in an ED than by ordering a termination pill, even if it is over the internet.”
Dr Murphy says it is disappointing not all maternity units are providing the service. “We don’t want people to have to travel, but there have been cases of women having to go from one hospital to another.”
Hundreds of GPs remain opposed to abortion, and to the provision of the service through GP surgeries, on ethical grounds.
“It’s just not for me at this stage of my career,” says one rural family doctor. “In the past I’ve helped women travel to the UK for abortions, and looked after them when they came back. On balance they were more upset after availing of the service.”
Pro-choice doctors, meanwhile, want to make their own changes. “We’d also like to see the HSE appoint a clinical lead for terminations of pregnancy,” says Thompson.
Access to free long-term contraception and changes to the three-day cooling off rule are also high on their list of proposed reforms.
