After the Eighth: Women and GPs on our fledgling abortion service
A year after the Repeal vote, Catherine Healy talks to women about their experiences with Ireland's new abortion services and - though grey areas persist - many are accessing care with ease
'Anne' remembers being asked if she was heading on holiday during the wait for a flight to London. "Going anywhere nice?" another passenger at Dublin Airport had cheerfully enquired. The reason for her trip defied casual explanation. "You're thinking, 'If only you knew what I'm about to go through,'" she says now.
Anne had received a severe foetal diagnosis two weeks before that day, getting the news just over four months into her pregnancy.
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"It was probably the lowest point in my life," she says. "The anxiety of having to organise a termination in another country completely consumed me. It was worse than even the grief and sadness."
With abortions usually only being available up to 24 weeks in Britain, Anne had rushed to find an appointment in a BPAS clinic before booking last-minute flights and accommodation.
"I started making calls just before the Easter bank holiday weekend," she says. "Some places could only do it up to 16 weeks, and others told me they'd phone back the week after. At the time, I just thought, 'I can't cope. I can't cope with this waiting.'"
Anne's story resembles many of the personal testimonies heard ahead of last year's referendum on the Eighth Amendment. But this is a post-referendum story: Irish legislation allows abortions to be carried out after 12 weeks in cases where a baby is unlikely to survive beyond 28 days of birth, a provision not applicable to Anne's circumstances. She travelled to the UK at the end of April, spending in the region of £900 on the procedure.
The maternity hospital she attended at home provided little support following her diagnosis, Anne says, beyond offering the names of British clinics over the phone after she called up. She remembers one midwife telling her she would "regret it for the rest of [her] life" if she decided to go ahead with a termination.
Anne is one of a small number of Irish-based women to have accessed care abroad since abortion became legal here on January 1, 2019. BPAS, one of the leading abortion providers in the UK, told Review that 35 women with addresses in the Republic had terminations at its clinics in that first month, falling to 13 in February and 11 in March. Most had presented at over 12 weeks of gestation, according to a spokesperson.
Calls to the British charity Abortion Support Network (ASN) are also down: 15 to 20 people a month have contacted its helpline from the Republic so far this year, compared to an average of 52 in 2018 and 57 in 2017. Mara Clarke, founder of ASN, says the Irish-based women its volunteers now hear from are usually seeking a later procedure, facing a diagnosis of severe foetal abnormalities, or more marginalised than the charity's typical clients. As an abortion fund, ASN will continue to support those who "fall through the cracks" of legal provision, Clarke stresses.
"I didn't expect the rollout [of abortion services in Ireland] to be as fast and successful as it was," she adds, however.
"I've been surprised at how many fewer calls we're getting."
The consensus among general practitioners on the ground is that implementation has been going well. Despite restrictions in the legislation, Irish women are now able to access early terminations through a local GP in most parts of the country.
"It was a very complex service to set up," says Brendan O'Shea, a Kildare-based family doctor who lectures in the School of Medicine at Trinity College Dublin. "It goes against the national psyche to say something has been successful, but I think the extent to which cooperation and coordination has been established between general practices, secondary care hospitals and the HSE is remarkable."
More than 300 GPs nationwide are estimated to be providing medical abortions up to nine weeks, with over 500 GPs being trained to deliver the service. Ten maternity units and hospitals take referrals for women who are between nine to 12 weeks pregnant, and more are expected to be added to the list of providers in future. The HSE's MyOptions helpline takes about 40 to 50 calls a day, according to a spokesperson, and demand for services has remained within predicted limits. No capacity issues are said to have been raised so far.
"Paula" was one of the first women to get an abortion at a local GP in Wexford. "I was dead set on what I wanted to do," she says, explaining that she had become pregnant after a failure of contraception. "I have three kids already. My family is complete."
The MyOptions number was her first point of contact: "I felt a bit lost, not knowing where to turn," she tells Review. "The lady on the phone was really understanding and talked me through how it would work, and where I could go."
Paula booked an appointment straight away, feeling relieved that she could attend a practice not far from her home. "No, I never considered going abroad," she says. "It would be far too expensive."
It was her second termination: Women Help Women, an online provider, had provided her with abortion pills during an earlier crisis pregnancy. That first experience was "traumatic", she says, describing her concern about not having access to a doctor in the event that something went wrong.
The GP visit was "clinical" but comparatively less worrisome, Paula adds. "There weren't many questions. It was only a few weeks after legalisation, and the doctor seemed a bit awkward about it. She just gave me the advice that was written in front of her."
The vast majority of women experience no complications during or after a medical abortion, according to Tiernan Murray, a GP in Goatstown, Co Dublin, and member of Doctors for Choice. "I phone up every woman two weeks after to see how they're getting on, and there's usually no problem at all. They've had a heavier, painful period and that's it."
Referring women on to hospitals once they pass the time limit for primary care should be straightforward, according to Murray. "If I have a woman approaching 12 weeks, I can make sure she's seen immediately," he says. "I have a folder of dedicated names and numbers if I need to get an emergency hospital appointment." Other doctors in the START group of GPs providing services say the same, he tells Review. "We can immediately contact an on-duty midwife or doctor in the hospital to facilitate an urgent referral."
In his own practice, he adds, women are typically seen within 24 hours of making their first call. "Most have made up their minds before seeing us and have looked up the MyOptions website. I give them the consent form and they come back three days later."
Pro-choice activists continue to firmly oppose that wait period, arguing that it creates an unnecessary burden.
"There is no medical basis for a three-day wait," says Linda Kavanagh of the Abortion Rights Campaign. "This is purely a political thing."
Siobhan Donohue of Terminations for Medical Reasons (TFMR) stresses that women seeking an abortion do not do so lightly.
"There are people in difficult circumstances - whether they have issues with childcare or getting away from work, or are experiencing domestic violence - who will find it difficult to return to a doctor within three days. We don't need to make this any more challenging."
Murray agrees. "It is such an insult to women," he says. "There is no other part of medicine where an adult makes a decision only to be told by a doctor, 'Go away and think about it. You might change your mind.' The thinking behind it is actually highly misogynistic. It presumes women can't be trusted to make up their minds. If someone isn't certain about the decision, like anything in general practice, we can advise them to come back to us in a few days, but it's wrong to force a delay."
The wait period is a particular obstacle for women from rural areas without easy access to services. Paula Dennan from the Kerry for Choice group highlights that most women in the county seeking a hospital appointment will have to travel to University Hospital Waterford. "It's a nightmare if you don't have your own transport," she says. "Getting to Waterford involves at least two buses, and people have to make that trip twice to get the procedure."
Couples in Northern Ireland have an even more difficult time. Abortion remains illegal across the Border in cases of rape, incest and fatal foetal abnormalities. It can be carried out only if a mother's life is in danger, or there is a permanent or serious risk to her mental or physical health. Northern Ireland-based women seeking a termination outside these circumstances have to accept a fee of €450 by service providers in the South, or pay to travel to Britain.
One such woman, "Carole", had a termination in the UK after receiving a fatal foetal diagnosis in October 2018. Carole was told at a 12-week scan that her baby had anencephaly, leaving no chance of survival. She remembers the upset of having to leave her toddler at home for the first time as she and her partner set out from Belfast. The two-year-old had sobbed as she left to stay at her granny's house for the weekend.
Although women from Northern Ireland can now receive free abortions in England, Wales and Scotland, uncertainty remains as to whether their own health providers can provide guidance on accessing services. "I had to make 27 different calls to understand what kind of care we could get," says Carole. "Getting the diagnosis was horrific, and then on top of that we had to be our own advocates. We really felt cut adrift."
The couple chose to have a communal cremation following the termination, she says. "At the time that was the least worst option. It would have been a different decision had we been able to stay at home."
Along with calling for fees to be abolished for women in Northern Ireland, Irish activists have urged the government here to press forward with plans to legislate for exclusion zones at GP surgeries. Murray's practice is one of several to have been targeted by protesters in recent weeks.
"We've had protests outside for the last three Saturdays. They turn up with posters saying, 'Real doctors don't kill babies,'" he says. "I think they do it because I'm the only provider in the area. Now it doesn't bother me because I'm not open on Saturdays, but their purpose is very clear: they want to stop other GPs from providing. Other local doctors driving past here, seeing them, are going to think, 'Oh, I don't want that outside my surgery.'"
Free contraception is another priority for doctors. "A lot of the young women I see would like to have the bar out it, but simply can't afford it," Murray tells Review.
O'Shea adds that no GP would like to see the number of terminations increasing. "In the next six months, there are two objectives: we need to continue streamlining the service and begin drawing conclusions about provision, but we also need to do a lot more work around sexual reproductive health."
Along with providing advice in private consultations, GPs and practice nurses are ideally placed to work with secondary schools on encouraging more effective use of contraception and avoiding unplanned pregnancies, he says.
Abortion services have been well received across the country, then, according to doctors, but complicated cases remain. Grey areas persist for pregnant women facing a diagnosis not considered to be fatal, Donohue points out. Clarke advises couples to book an appointment in a British clinic if there is a chance they will be turned down by Irish services, leaving them with little time to arrange for a termination across the water. "We also tell callers they don't have to put themselves through that process [of receiving confirmation of a fatal diagnosis from two doctors] if they don't want to," she tells Review.
More work remains to be done, says Kavanagh. "The Repeal messages about people feeling exiled and traumatised having to go abroad are still relevant. We've always campaigned for free, safe and legal abortion. The challenge now is ensuring free, safe, legal and local services for everyone who needs them."