Saturday 25 May 2019

Dr Brendan O'Shea: 'How to keep abortion numbers down? Free contraception and better education'

Delays: Given rigid timelines, early pregnancy is sensitive. Ultrasound needs to be available within days. Picture posed
Delays: Given rigid timelines, early pregnancy is sensitive. Ultrasound needs to be available within days. Picture posed

Dr Brendan O'Shea

The first call to our practice on January 2, at 9.01am, was a hesitant voice requesting an appointment regarding a crisis pregnancy.

The health system had been on six months' notice that early medical termination of pregnancy was 'switching on' from January 1, particularly the 180 general practices where a GP and practice team had opted into the scheme.

The Irish College of General Practitioners' (ICGP) women's health programme had communicated intensely with GPs, devising under the most unsparing and critical gaze of the nation evidence-based guidelines, in keeping with new legislation and best practice.

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Parts of this went well, parts have been gritty. Medication supply by the HSE was a bit hit and miss. Some GPs and pharmacists had none at start-up, and initially one of the two necessary medications was supplied at the wrong dose (Mifepristone at 600mg instead of 200mg) - all unfortunate given that pills were the simplest, least expensive piece of it.

Putting a public patient in a room with an ultrasound for 10 minutes in a timely manner also caused cataclysmic eruptions. Ultrasound is indicated in about one in six cases, mainly where doubt exists regarding how far on pregnancy is, or if ectopic pregnancy is suspected.

Given rigid legal timelines, early pregnancy is time sensitive. Ultrasound needs to be available within days. "The first ultrasound took only 11 phone calls to arrange," observed one GP wryly.

While The Irish Family Planning Association and many hospital obstetric units held out for extra funding for additional ultrasound capacity, it was never going to happen that Irish GPs and their patients on the front line would be supported with GP point-of-care ultrasound, increasingly common in affluent countries. Did someone mention Sláintecare?

Blood grouping is required in a small number of cases, but our laboratory only managed to issue paper forms to practices by January 29; the lab would only do the test with the correct paper. Yes Minister!

The My Options phone line has been effective. A collaboration between the ICGP and HSE, it is evident staff have been compassionate, smart, effective and professional. Women, in many instances accompanied by partners, friends or family members, have 'made it' to opting-in practices in very substantial numbers.

As I write, people access the service in all but four counties. Numbers of participating practices continue to increase above 200.

Women are astonished it is a free service. Participating GPs ask how did women ever manage before? Most women are fraught with anxiety. Anecdotal accounts abound, like the woman from Co Wicklow who could only get an urgent ultrasound in Cork, or the 43-year-old mother of three adult children admitted early one morning for a cholecystectomy in St Elsewhere's. Her standard pre-operative pregnancy test was unexpectedly positive. Deferring her long-awaited gall bladder operation, she took herself and her gallstones from St Elsewhere's and, directed by My Options, she was seen in an opting-in practice while on the way home to consider termination.

Some believe an afternoon in Manchester might still be more manageable. Many travel to opting-in practices, returning again for second visits after what is condescendingly known as the 'cooling-off period'. If they need to travel for ultrasound, it's three visits. Apart from the stress of this while cold, anxious, tired and nauseated, for many the issues of concealment and confidentiality are clearly pressing, together with practicalities of childminding. These women dance to the admonitory tune of the new system.

Knowledge about contraception is absolutely frightening - high-volume, high-risk unsafe sexual activity by men and women is clearly evident. It is who we are.

By year end, we will have a new number to worry about - the number of Irish abortions. We have to start immediately, working hard and intelligently to reduce it.

Two things are necessary. Make free contraception available for all sexually-active citizens. A baseline of three GP consultations in two years will do this, only a proportion of which will be taken up (not all will be sexually active and most men will not require them). The cost is a drop in the estimated €22bn ocean of total Irish health spending. All other EU citizens have this, but ours is still a pariah state, our citizens sheeplike, and a few too many politicians have a mean strategic vision.

The second thing we need is intensified communication around effective reproductive health, with renewed public health messaging. Parents, GPs, practice nurses and teachers should collaborate locally to deliver effective, friendly, informed, reality-based sexual health education to transition year students. Honest efforts by teaching staff in schools have failed to date. This needs to be acknowledged and improved. Many bitterly pro-life and pro-choice people can unite on this. The women's health programme at the ICGP is now The ICGP sexual and reproductive health programme.

Taking rough with smooth, our new, imperfect and evolving system of GP-led care will hugely reduce numbers of later surgical abortions, and is globally innovative in this regard.

Delivering this safer service in primary care is better for people. But there is more to do.

Irish Independent

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