Elaine Loughlin: Abortion services in Ireland can feel like a black-market amenity

This is the real-life experience of one woman presented to members of the Health Committee this week, but it is reflective of many who have tried to navigate a system that in some instances is equivalent to a black-market amenity in how it operates and in other cases blocks women from accessing services.

Examples of women paying €90 taxi fares to get to a GP offering terminations in a region where few do, and a woman who phoned seven GPs before one referred her to the HSE termination service MyOptions, were also heard during the Oireachtas Health Committee.

There is no list of who to go to if you need such care, you can’t simply Google GPs who provide abortion services.

“It is much more demanding to access this form of healthcare than any other form of healthcare,” said Dr Catherine Conlon, who was involved in the independent review.

While GPs who provide care can register with MyOptions, 40% have decided not to do so, largely because they fear the extra workload.

Four years after abortion services were supposedly rolled out, we have a disjointed network of GPs who are often overstretched and in some cases without local support should an emergency arise as only 11 of the 19 maternity hospitals currently offer terminations.

As a result, women are often forced to “run the gauntlet” in phoning GPs in the hope that they might find a doctor who will see them.

Patients being misled

Perhaps most worryingly, this has resulted in instances where doctors have intentionally misled patients in a bid to block them from accessing services by taking advantage of the 12-week limit in place.

“They are attending certain centres where they’re being told they are much earlier on in their pregnancy than they are, scan results have been misinterpreted to say that they are earlier in the pregnancy than they are, to my mind that is coercively controlling somebody’s reproductive rights,” said Marie O’Shea, the senior barrister who reviewed Ireland’s abortion laws.

It was also pointed out by Green Party TD Neasa Hourigan that the current legislation means there is no criminal aspect to denying somebody service, but there is a criminal aspect to delivering service.

Not even O’Shea, the person tasked with examining termination services in this country, can say exactly how many GPs are now providing abortion services or where they are, despite seeking this information in the course of her work.

While 422 contracts have been entered into, she told politicians this week that there is no way of knowing whether these contracts represent a single doctor or many GPs working in a large practice.

“We do not have data to know how many GPs provide the service. All we have is data to say how many contracts have been signed by providers in general practice. We know 10 of the 422 are organisations including Well Woman, the IFPA, and perhaps student union bodies,” she told members of the committee, adding that the assumption is there are multiple GPs providing services within those organisations.

Clare senator Martin Conway told the committee of how he had tried, but failed, to put together a resource for women in his own constituency.

“Around two years ago my office tried to do a body of work to establish the providers who were providing, and who were not providing. The difficulties we had, as an office of a public representative, in trying to establish that information so as to have it for people who contact us were astounding.”

There are of course a number of reasons why GPs have opted not to provide abortion care.

Failures within system

Conscientious objection is a clear-cut reason why some healthcare professionals would refuse, as is their right. However, the failings within the healthcare system are also having a major impact on the rollout of services.

With shortages of GPs across the county, O’Shea cited workforce as “one of the major barriers” as family doctors carry an excessive workload even without taking on abortion service. So much so that many GPs, who are committed to providing care to women, schedule appointments with patients after hours, early in the morning, or at lunchtime.

Some GPs even admitted to giving women their own numbers for follow-up.

However, this is not a sustainable model, and ultimately, we cannot rely on a number of highly committed practitioners to cover what should be a service offered by all or at least almost all.

“The intent of this model of care was normalisation within general practice but the effect of the roll-out in a small number of GPs is that it is not operating in a normal way and is having an adverse impact on providers and those accessing care,” Conlon told the committee.

While many GPs are comfortable in offering services, they are reluctant to make it widely known. O’Shea summed this up: “If you have an excessive workload capacity and cannot handle it, particularly in a county like Monaghan where there is one contract, you would not want every single person in that county coming to you because you could not provide the service.”

To ease the workload, O’Shea suggested that other healthcare workers could be given the power to administer or carry out some abortion services as is the case in other jurisdictions such as New Zealand.

The World Health Organisation guidance, which is evidence-based, would very much support expanding the range of workers beyond medical practitioners, to allow nurses, midwives, and even pharmacists in community settings to provide the services.

In a bid to introduce services across all maternity hospitals, she suggested what would likely be a contentious solution in providing interviewing panels with the authority to ask prospective consultants if they have a conscientious objection.

While safe access zones, which would have banned any protests directly outside healthcare practices providing abortion services, were due to be introduced in tandem with legislation to repeal the Eighth Amendment, this has yet to happen.

The lack of safe access zones and the threat of protests have undoubtedly been a deciding factor in some opting not to provide services and have been an added stress for those who do.

This was evident when O’Shea spoke to GPs who have seen protesters turn up outside of their clinics.

“They wondered about the effect that was having on all patients coming into the clinic, not just those seeking termination of pregnancy," she told the Oireachtas Committee.

"They wondered whether people who worked in the clinic had voted against repeal and how they felt. Were they being looked at in some way and feeling perhaps compromised by that?

"Another GP in a rural area wondered whether the protesters knew where she lived. She was worried that they would possibly present to her house. I heard many accounts directly of people worrying about protesting. Certainly, it seems to have an impact on those particular providers.”

While abortion care was in theory introduced as a national service in 2019, in practice there are large pockets around the country where this care is not available.

It results in logistical problems and puts financial pressure on women who must travel significant distances, it’s an ad-hoc system that only serves to perpetuate a stigma around abortion.

Before looking to extend or alter services and the three-day wait, maybe we should be addressing a service that is patchy at best and paternalistic at worse.