Confusion and constraints: Abortion in the real world
At the hospital where a tragic death kicked off the drive to repeal the 8th, nursing staff have raised concerns about resourcing and managing abortion services. Lorna Siggins reports from Galway
'So it's a Friday evening, theatre finishes at 6pm, and there are three staff on duty in the maternity wing after 8pm.
"The nurses then hear of a woman who has been admitted through accident and emergency, and who is bleeding and may require an emergency procedure."
"The nurses don't have any administrative back-up, and are trying to organise extra staff to facilitate opening a second theatre in the maternity unit. All this is being done while looking after patients. "
"The senior house officer and registrar may have to manage this situation without talking to the consultant, and the woman who is bleeding may not get scanned because there is no trained ultrasonographer on duty."
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"At this stage, she is still in casualty, but may be deemed critical and may have to be moved to emergency theatre for an ERPC (evacuation of retained products of conception - a procedure used to manage a miscarriage, also used when a medical termination has failed)."
"The nursing staff are dealing with administrative mayhem, while also dealing with two critically ill patients. Eventually, these two women will recover side by side, separated by one single curtain."
This is a description - provided by a reliable source - of how abortion services can work in the real world of the Irish health services, and in this case, specifically at University Hospital Galway (UHG), the hospital at the centre of the Savita Halappanavar case.
The 31-year old Indian-born dentist died after a septic miscarriage on October 28, 2012 in University Hospital, Galway (UHG). Halappanavar had requested a termination several times when she was admitted to hospital, but was refused under existing legislation as a foetal heartbeat was detected.
On May 26, 2018, the Galway Together for Yes campaign was celebrating after confirming that the Galway West constituency had recorded a "Yes" vote in the referendum to repeal the Eighth Amendment to the Constitution outlawing abortion. At 65.9pc, Galway's vote was just below the national result of 66.4pc, and all four offshore islands in the constituency had voted for repeal.
Legislators moved swiftly, and abortion services have been available across the country since January 1, 2019 under the Health (Regulation of Termination of Pregnancy) Act 2018.
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.
However, the Abortion Working Group, a coalition of 23 groups chaired by the National Women's Council of Ireland (NWCI), said late last month that Ireland still does not have the women-centred service people voted for.
In a statement issued on December 19, the group said that "willing providers are struggling to provide an abortion service due to a lack of leadership and institutional support".
It has been confirmed this week that the HSE has appointed a part-time clinical lead - Dr Aoife Mullally, obstetrician at the Coombe Hospital in Dublin.
The two-day a week post will require her to provide clinical leadership for implementing "safe, evidence-based, quality-assured, woman-centred, accessible services for women who require abortion care".
UHG is one of the 10 maternity units, out of a national total of 19, which have signed up to participate in the provision of abortion services, along with Mayo General Hospital in Castlebar - both run by the Saolta healthcare group.
Medical sources in Galway say the new service is working well - at both primary care level with GPs, and in UHG - and that every effort is being made to ensure that women admitted for elective procedures, or for procedures arising from complications, are accommodated.
However, nursing staff have claimed that lack of resources and confusion over interpretation of guidelines regarding abortion services have been causing difficulties.
Last September, the Irish Nurses and Midwives Organisation (INMO) contacted Saolta to express concern about what they called an "ad-hoc system".
Staff in the Galway hospital's maternity wing gynaecological theatre were concerned about the handling of certain cases where women had developed complications after being prescribed medication to trigger abortion in primary care settings.
The staff held a meeting with hospital management over staffing and theatre availability, accurate recording of terminations, and the right to conscientious objection.
A terminology issue
Under the legislation, a woman who develops complications after being prescribed medication by a GP for a termination within 12 weeks can have a non-elective termination in hospital. These cases have not been recorded as terminations, but as "evacuation of retained products of conception" or ERPCs.
Nursing staff in Galway who questioned use of this term were told that this was because a previous medical term - "spontaneous abortion" - was regarded as insensitive.
However, the nurses had several issues with this, pointing out that if all categories of termination procedures were not being recorded, including ERPCs, this could affect resources for both staffing and aftercare.
There were also questions over whether all such patients had been scanned after admission through accident and emergency to ensure the legislation was complied with. It is understood that this is still an issue of particular concern at weekends, where there may not be adequately trained staff available to conduct scans.
A more sensitive issue raised with management was the right to exercise conscientious objection, which is allowed for under section 22 of the Health (Regulation of Termination of Pregnancy) Act 2018, and is limited to staff involved in the delivery of the treatment only.
The nurses' union, the INMO, said it had already heard of a situation where nursing staff in one west of Ireland hospital were asked to define the "level" of their conscientious objection. The legislation makes it clear that conscientious objection cannot be invoked in an emergency situation, when the risk to a pregnant woman's life or health is immediate. All ERPCs are, by definition, treated as emergency situations.
Asked about these issues, Saolta said that "there are processes in place in each maternity department for the management of concurrent emergencies".
Asked to confirm how many extra nursing staff had been employed for terminations in its Galway and Mayo hospitals, and whether there is a dedicated theatre, the Saolta group said that "in both of these units, additional staffing was put in place to facilitate the provision of this service, and the necessary theatre time was identified in the existing theatre schedules".
Saolta did not specify the number of extra staff appointed. It is understood that it amounts to one extra nursing post in UHG.
INMO regional representative Anne Burke said both resources and clarity over conscientious objection were issues under discussion with management.
"The HSE doesn't want to engage in these issues and refers us to local management, but there is still no clarity at local management level," she said.
Figures for terminations will not be available nationally until on or before June 30, 2020.
Anecdotal evidence from medical sources suggests that take-up of abortion services is low, but the largest cohort is with general practitioners (GPs), some 15pc (347 to date) of whom have signed up.
Dr Peter Boylan, former master of the National Maternity Hospital in Dublin's Holles Street and author of the recently published In the Shadow of the Eighth (Penguin), says his impression is that the system is working "very well" at a national level.
Dr Boylan was a member of the advisory group on the new legislation. He said issues raised by nursing staff, such as recording ERPCs in hospitals, should not pose a difficulty. Women who would have first approached their GP for medication would be recorded at that stage, he says.
"In a situation where there is an ERPC, the pregnancy is already over," he says. "If the hospital were to record this as a termination, it would then be recording the same procedure twice."
National Women's Council (NWCI) women's health coordinator, Cliona Loughnane, believes the figures for terminations and other data collated should be published before next June.
The Abortion Working Group is relying on anecdotal evidence for now in relation to figures and to how the system is working, Loughnane said.
The NWCI is concerned about adequate geographical cover for terminations, given that nine maternity hospitals are not participating in abortion service provision. This means women with complications who are living in a non-participating hospital area still have to travel distances, she says.
It limits options for GPs and patients, and is particularly critical given the 12-week time limit for terminations and the three-day waiting or "cooling off" period before women can have access to medication, she says.
Labour senator Ivana Bacik is critical of this "cooling off" stipulation, and hopes to see it removed when the legislation comes up for review.
Loughnane welcomed the establishment of the HSE unplanned pregnancy freephone helpline, My Options.
Loughnane also pointed out that Harris had promised to introduce legislation on exclusion zones around healthcare centres providing abortion.
The aim of these zones would be to protect clients from protesters. The promised legislation is not even listed as a priority in the current programme, she notes.
In several parts of the midlands, west and north-west, protests took place from early in the new year outside primary healthcare centres, with participants carrying crosses and bearing placards, with phrases such as, "Doc, if she's not sick, she's not a patient, just a paying proposition" and "Doctor? Merchant of misery more like!"
Independent TD for Galway West Catherine Connolly concurs with the NWCI that any available information collated by the minister's department should be made available now.
In a Dáíl question last month on whether additional resources had been allocated to hospitals for provision of abortion services, she was told that €12m was provided in 2019 for the implementation of termination of pregnancy services, some €7m of which has been allocated for provision of the service in the acute hospital system.
The HSE told the Irish Independent that the new clinical lead will chair an advisory forum, which will have representatives from the provider organisations, as well as other key stakeholders.
Asked to comment on the recording issue, the HSE said that "all terminations must be notified to the minister in accordance with section 20 Health (Regulation of Termination of Pregnancy) Act, 2018" and "where a woman presents with a complication of a termination, this will be recorded locally, depending on the intervention required".
In a separate response to Connolly, the HSE's national women and infants health programme general manager Mary-Jo Biggs said that hospitals aim to treat every woman with "dignity and respect".
However, it said there may be occasions "due to the demand for the termination service and/or competing demands from other areas of the hospital - for example, infection control requirements" where the location of the woman during patient management is "not ideal".
Biggs said that "data in relation to the number of incidences" of this nature is "not available or routinely recorded/collated within the health service".