Trinity College Dublin: New study finds Irish abortion services working well, but needs of some women not being met

Abortion services in Ireland are overall working well and are being delivered by committed healthcare staff, however the needs of women seeking abortion services for severe foetal abnormality are not being met, according to new research published today [Tue, July 12th].

The Unplanned Pregnancy and Abortion Care (UnPAC) study, led by Dr Catherine Conlon, School of Social Work and Social Policy, Trinity College Dublin was published today. The study was commissioned by the Health Service Executive (HSE) Sexual Health & Crisis Pregnancy Programme.

The study presents data on women’s experiences of accessing unplanned pregnancy and abortion services in Ireland since the enactment of the Health (Regulation of Termination of Pregnancy) Act 2018.

The report will inform the service-user strand of the Government’s review of the operation of this legislation and sets out a number of considerations for this process. These include replacing the three-day mandatory waiting period following certification of pregnancy with an optional second consultation. In relation to fatal foetal anomaly, the criteria for qualification under section 11 of the Act and the role of hospital multidisciplinary teams need to be reconsidered and the ‘chilling effect’ of criminalization needs to be considered as part of the review.

The qualitative study involved in-depth interviews with 58 women who accessed unplanned pregnancy and abortion services, making it one of the largest and most rigorous studies of its kind. It provides a comprehensive description of the experiences of women, taking account of differing backgrounds, ages and locations. The interviews took place between December 2019 – April 2021.

Key findings of the study include:

The HSE unplanned pregnancy support service, My Options, is serving people well in being a responsive, accessible, caring and continuous element of the care pathway.
Doctors in primary care providing the service are committed, caring and supportive.
Women who self-present to GPs ‘run the gauntlet’ as some GPs who are not providing services are not referring women on to My Options or another provider. This has the effect of creating barriers to timely care or even obstructing access.
Some participants had difficulty accessing appointments in their area due to sparse coverage. This is a particular issue in rural areas.
Women are generally clear on their decision and are anxious for timely access which is at odds with the mandatory three-day waiting period.
Those cared for by doctors in the community self-managed the abortion procedure at home, which was positively accepted by those interviewed, as the comfort and familiarity of home allows for privacy and personal space. However, the need to have a private, comfortable space meant some women had to arrange to stay with friends or book a hotel. This raises issues for women in situations of domestic abuse or who are homeless.
Qualifying for abortion care post-12 weeks’ gestation under section 11 of the Act was portrayed by women as protracted and highly restrictive. In cases of complex multiple anomalies, indicating severe life-limiting conditions, women described themselves as hoping for a ‘fatal enough’ diagnosis so they would be cared for at home. Many still must travel. In 2021, 206 women left Ireland to access abortion services.
These women felt let down, and angry at a time of acute loss and anguish when they had understood legalization meant they would get care in Ireland.
In addition, participants described experiencing a ‘chilling effect’ associated with the criminal provisions in the Act in their interaction with clinicians where diagnoses were inconclusive, or women did not satisfy the criteria to qualify for termination care in Ireland.
Dr Catherine Conlon, lead author of the study, said:

“From listening to the experiences of the 58 women we interviewed for this study it is clear that legalising abortion in Ireland has enhanced women’s well-being, dignity and autonomy. Provision of abortion care under 12 weeks’ gestation is working well and women reported quality, acceptable care from conscientious, committed providers.”

“Those seeking care regarding foetal anomaly, however, did not feel the service met their needs and described a protracted assessment process from which they felt heavily excluded. Many women seeking care do not qualify under section 11 of the Act. We know from international data that women continue to travel abroad to access abortion services and now our research illustrates how these women and their families feel let down, angry and bewildered at a time of acute loss and anguish.”

The author sets out a series of considerations drawn directly from service users’ experiences for the review of the operation of the 2018 Act that is currently underway.

These include:

Women presenting for care under 12 weeks’ gestation are generally clear in their decision and want care as timely as possible. This is inconsistent with the mandatory three day wait prescribed in legislation. Service provision based on one consultation, with an optional second consultation, would make for a more acceptable model of care.
The ‘chilling effect’ of criminal provisions in the legislation on accessibility and quality of care should be considered as part of the Review of the Operation of the Act.
Criteria for qualification under section 11 of the Act in relation to fatal foetal anomaly and the role of hospital multidisciplinary teams set out in the Clinical Guidelines need to be reviewed in light of this study’s findings.
Doctors who do not provide abortion services must exercise their duty of care to provide information and refer women seeking abortion services to settings where they can access care at the time of their first presentation.
Regional provision of abortion services by GPs and women health centres needs to be expanded. Women are clear they do not want doctors as the only mandated providers of services.
Remote consultations introduced in response to Covid-19 were shown to enhance accessibility of care and should be retained in the model of care on a permanent basis to make for an optimally accessible, responsive service.
Abortion services should be integrated in all maternity hospitals or maternity settings having regard to capacity, resource, and values impediments to provision.
Self-managing community-provided early medical abortion requires a person to have a safe, private place where they can care for themselves while administering the medication. Inpatient day-care facilities in community/primary care settings should be developed.
The role of counselling should be expanded beyond community provision to ensure women seeking abortions under section 11 of the Act have access to supports.
Availability of surgical methods of abortion in Irish hospitals is currently very limited and should be expanded to achieve choice.