Saturday 19 January 2019

Abortion in Ireland: How would it work?

If we vote to remove the Eighth Amendment from the Constitution, how would the state organise the ­provision of safe, legal abortion? Katie Byrne considers what we know so far

Waiting: Once the woman makes clear her intention to have an abortion, there would be a 72-hour 'pause period' between the initial assessment and the termination of pregnancy
Waiting: Once the woman makes clear her intention to have an abortion, there would be a 72-hour 'pause period' between the initial assessment and the termination of pregnancy
Katie Byrne

Katie Byrne

It's less than a month until the Referendum on the Eighth Amendment and uncertainty abounds.

Earlier this week, the Referendum Commission, an impartial, independent body, published guidelines reminding voters that a 'Yes' vote gives the Oireachtas full authority "to pass laws regulating the termination of pregnancy". However, there is no guarantee that TDs and senators will reach agreement on the proposed legislation.

In February, Health Minister Simon Harris indicated that the envisaged abortion-service would be GP-led. The National Association of General Practitioners (NAGP), which represents more than 2,000 Irish GPs, immediately objected to that assumption.

In a statement released by the association, Dr Emmet Kerin, President of the NAGP, said: "I was alarmed to hear the Minister's comments and presumption that the State would direct GPs to lead an abortion service without any engagement with our members to discuss the implications of this notion."

The Royal College of Obstetricians and Gynaecologists released a statement this week saying they are ready to train Irish doctors to provide abortion services, should the referendum be passed.

Draft legislation published in March refers to the broader-stroke term 'medical practitioner', which is further defined as "all registered medical practitioners on the Medical Council register".

The paper outlines 21 policies that "would only be relevant in the event that the proposed referendum on Article 40.3.3 is passed". If the Eighth Amendment is repealed, "these policies will require further scrutiny, refinement and definition taking account of legal advice from the Office of the Attorney General".

The most contentious policy is the proposal to legislate for abortion up to 12 weeks of pregnancy (which means 10 weeks after conception) "without specific indication". Terminations after this period would only be available in exceptional circumstances.

The 21-policy plan gives a broad idea of the abortion scheme that the Government endeavours to regulate, should the Eighth Amendment be removed from the Constitution. The finer details have yet to be revealed to the public.

The Government has engaged with a number of senior medical practitioners to discuss clinical protocol, best practice and safeguards in the lead-up to the referendum.

There would be further consultation if the proposed legislation is passed.

We've explored the potential clinical practicalities of an abortion scheme in Ireland - and highlighted the questions that still need to be answered.

Where would a woman go if she wanted an abortion within the first 12 weeks of pregnancy?

Early abortion services would be provided in a primary care setting. This is in keeping with new World Health Organisation recommendations, which identify primary care medical practitioners as the safest providers of abortion in early pregnancy.

The Doctors for Choice group believes that a GP-led abortion service of 100 "champion practices" located across the country, coupled with non-GP groups like the Irish Family Planning Association, would be enough to meet women's needs.

GP uptake would be easy to achieve in cities and larger counties but could be more challenging in rural areas.

What if the medical practitioner refuses to perform an abortion?

The right to 'conscientious objection' for medical and nursing personnel is provided for in the policy paper. A medical practitioner could object to performing a procedure so long as they refer the patient to a doctor who could meet their needs.

This would be an uncomfortable situation for both doctor and patient so it is much more likely that women would be able to access a website, similar to that provided by the CervicalCheck programme, which would help them find ­participating medical practitioners in their location.

Could the woman have an abortion on the same day?

Once the woman made clear her intention to have an abortion, there would be a 72-hour 'pause period' between the initial assessment and the termination of pregnancy, to ensure a fully considered decision.

It is not clear if this time limit would be waived in the case of an emergency, as it is in Portugal, another Catholic country with a mandatory three-day wait period.

Would an ultrasound scan be required?

A spokesperson for Minister Simon Harris said the 72-hour waiting period would allow a doctor to refer a woman for a scan if it is clinically determined to be necessary.

In Britain, the British Pregnancy Advisory Service (BPAS) performs an ultrasound scan on all women requesting a termination, irrespective of gestational age.

If the pregnancy is too early to be visible on ultrasound, a small ultrasound probe may be inserted into the vagina.

If pregnancy is not visible on a vaginal scan, this could indicate an ectopic pregnancy (when a pregnancy occurs outside of the uterus). According to the World Health Organisation, ectopic pregnancy is "an uncommon, but potentially life-threatening event", occurring in 1.5-2pc of pregnancies.

How would gestational age be measured under nine weeks without a scan?

The pregnancy would be dated from the woman's last menstrual period, which is approximately two weeks before conception. In general, the policy is that termination would be available where a medical professional has certified that the pregnancy does not exceed 12 weeks

What would happen next?

Once the 'informed consent' protocol has been met, and the woman's medical history has been assessed for potential contraindications, a combination of two medications, otherwise known as the 'abortion pill', would be prescribed. The first medicine, mifepristone, would end the pregnancy by blocking the hormone progesterone. The second medicine, misoprostol, would make the womb contract, and induce the loss of a pregnancy, similar to a miscarriage.

Would a woman take both medicines at once?

In general terms, if a woman is under nine weeks pregnant, she could take both pills together and complete the abortion at home. It is likely that she would be provided with pain relief and antibiotics to prevent infection.

Misoprostol causes cramps and heavy bleeding, which is why many women choose to wait until a Friday evening before taking the medication. The World Health Organisation recommends that "facility-based abortion care should be reserved for the management of medical abortion" in pregnancies over nine weeks.

In this scenario, misoprostol might be administered 1-3 days later, in a hospital setting, where the patient could be monitored throughout the procedure.

What if there were complications?

According to research, just under 10pc of women who take the abortion pill at home seek medical attention. Some of these women would require gynaecological intervention in a hospital setting. In Britain, women can call a 24-hour nurse-led service for aftercare advice. A similar service would have to be offered here.

Medical abortion has a very good safety record but there are some risks. Excessive bleeding occurs in about 1 in every 1,000 abortions and, in some cases, requires transfusion.

Infection is another risk, which is why antibiotics would likely be prescribed as a matter of course.

How could a woman confirm that the pregnancy has ended?

Reduced bleeding and cramping usually indicates that the pregnancy has ended. If a woman is under nine weeks pregnant, she would more than likely self-assess by monitoring her 'before' and 'after' symptoms, including nausea and breast tenderness. An absence of bleeding may indicate that the pregnancy is ectopic. (Mifepristone and misoprostol do not terminate ectopic pregnancy.)

The continuation of pregnancy, and the risk of some of 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.

Would there be follow-up care?

The thinking is that a woman should have a check-up four to six weeks later to make sure she has recovered physically and emotionally.

Would a woman choose the type of abortion she has?

Women can choose between a surgical abortion and a medical abortion in other jurisdictions but it is not clear if women would be given the same option here.

Surgical abortion would take place in a hospital setting and would most likely only be performed on women who experience complications through medical abortion, or, in exceptional ­circumstances, women who are more than 12 weeks pregnant.

What is meant by 'exceptional circumstances'?

Three things: a serious risk to the life or health of the mother, a determination that the foetus has a condition likely to lead to death before, or shortly after, birth and emergency cases, where there's an immediate risk.

Two medical practitioners would be required to assess termination of pregnancy on the grounds of risk to the health of a pregnant woman, and the grounds of a foetal condition "which is likely to lead to death before or shortly after birth".

A spokesperson for Simon Harris noted that the proposed requirement to certify that the foetus has not reached viability - which doesn't apply in the UK - would be "an effective ban on later-term abortions". The definition of viability is the point in the pregnancy at which, "in the reasonable opinion of a medical practitioner, the foetus is capable of sustained survival outside the uterus".

If viability is established, and the pregnancy is still ended on health grounds, then it would be done through early delivery, with a full medical team on hand.

What kind of training would medical practitioners receive?

Clinical guidelines would be produced by the relevant colleges and medical authorities that doctors would adhere to. Dr Tiernan Murray of the Doctors for Choice group estimated that a "two-hour intensive training session" would adequately prepare first-line medical practitioners for medical abortion practice. The training for surgical abortion in the field of obstetrics and gynaecology would be more extensive.

How much would an abortion cost?

This is not clear. It is expected that the service would be made available in the public health service.

In reality this would mean that women would still have to pay in order to visit a doctor, or a clinic, outside the public hospital setting, unless they have a medical card. They would also have to pay for medical abortion pills unless they have a medical card.

Women getting later abortions, due to health problems or because they are carrying babies with fatal foetal abnormalities, would be able to access public hospitals.

Would contraception then become free?

There are plans to improve this area independent of the Eighth Amendment vote. Minister Simon Harris is planning to launch a programme on sexual health, a possible extension to the provision of emergency hormonal contraception and an extension to the availability and distribution of free barrier contraception.

Would post-abortion counselling be provided?

The Government has indicated that the process of informed consent would include "access to impartial counselling, if necessary, on the advice of the doctor". We can therefore assume that access to post-abortion counselling would also be available. We were unable to ascertain if this service would also be available to men affected by abortion, or if the service would be free or subsidised.

Would women under the age of 18 require parental consent?

This is not yet known. In Britain, BPAS treats teenagers aged 12-17 without parental consent, unless they believe they are s in "serious danger", but they do require someone over 18 to bring them home. In Italy (where abortion is legal but hard to obtain due to the high rate of conscientious objectors within the medical community), under 18s need the consent of a parent or guardian.

Would private abortion providers open here?

While abortion is funded by the NHS in the UK, a small minority of women still choose to attend a private clinic for convenience and confidentiality. It is too early to know if private clinics would open here.

A spokesperson from Marie Stopes, Britain's largest abortion provider, said there are currently no plans to provide services in the Republic of Ireland.

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