Maeve Sheehan: 'Doctors divided as HSE rushes to tick boxes on abortion'
Pressure is mounting for the January 1 start date for termination services to be put back
There are 22 days to go before the roll-out of abortion services on January 1. It should be a historic occasion when the overwhelming support shown by Irish voters for a woman's right to choose becomes reality.
But as the deadline looms, disquiet among some doctors that it is ambitious to the point of being unsafe has grown louder.
Doctors who campaigned strongest for a Yes vote in the referendum are now questioning the January 1 start date, chosen by Health Minister Simon Harris, and complaining about the lack of clarity.
Pressure on the minister mounted last Friday when the former master of the Coombe maternity hospital, Dr Chris Fitzpatrick, publicly argued that the start date should be pushed back.
In an excoriating column, he wrote that rushing in abortion services with inadequate planning and insufficient resources would threaten the health and well-being of women.
He also revealed that he had signed a motion that the Institute of Obstetricians and Gynaecologists should convene an extraordinary general meeting to discuss the safety and readiness of the abortion service. Such a meeting can be convened after 28 days, by which time Mr Harris's deadline will have passed.
Dr Peter Boylan, the obstetrician and campaigner who is advising the Government on the roll-out of abortion services, has described these concerns as a "fear of change".
However, a more pressing factor is likely to be the information vacuum separating doctors from the Health Service Executive, with GPs on the front line of introducing an entirely new abortion service for women, yet still waiting for written guidance on how they are going to do that just three weeks before it is to be rolled out.
When she spoke to the Sunday Independent late last week, Dr Trish Horgan, a GP and member of pro-choice doctors Start, said they were still in the dark about basic information, from everything such as whether GPs should expect deliveries of medication to clinical guidelines on the care that they must provide.
"This is a new service and completely new in Ireland. There are several outstanding issues which need to be resolved to facilitate the January 1 deadline. Each of these issues is a critical piece in the jigsaw and it is difficult to see full implementation without the full picture," she said.
The broad strokes of what will happen are clear. The first port of call for women seeking advice on unplanned pregnancies will be a 24-hour helpline. Those seeking information on terminations will be referred to a GP in their area who has 'opted in' to provide abortion. There will be three GP visits in total. Women will first be assessed. There will be a three-day 'cooling-off' period before they are prescribed the abortion pill, followed by a final GP visit. Women who are between nine and 12 weeks pregnant will be referred to a maternity unit. GPs will prescribe abortion pills for women who are less than nine weeks pregnant.
The finer details have yet to become clear. Dr Horgan listed 10 uncertainties that are fuelling the unease among some GPs as the countdown to the roll-out of the service begins.
These include practical issues such as the medication - an abortion pill of mifepristone and misoprostol combined. "We need to know how we will order them and how they will be stored," she said. "It is a logistic that needs to be worked out before January 1."
The same goes for special, low-sensitivity pregnancy testing kit that GPs will use after the procedure.
"These low-sensitivity pregnancy tests need to be specifically ordered and are not ones you can buy in a pharmacy," said Dr Horgan. "It's a small issue but an important issue in terms of ensuring completion of the process."
GPs will also need "rapid access to ultrasound", she said, for the small percentage of women who will require scans, to assess their stage of pregnancy or other issues. "It needs to be local and we need to get a result back quickly. We also need to agree the mechanisms of referral to ultrasound, whether that will be secure online referral and we need to get results back in a secure way as well," Dr Horgan added.
GPs are also waiting guidance from an expert clinical group, which is examining whether women undergoing a termination should be tested for rhesus-negative blood grouping and offered Anti-D if positive. If a woman is rhesus negative and the foetus is rhesus positive, the interaction between their blood groups could affect future pregnancies. There is a low risk that bloods will mix with the abortion pill - it is more likely in surgical abortions. The expert group is examining whether the option should be offered. "It is a clinical issue - but it has yet to be sorted. We are awaiting advice from the experts," Dr Horgan said.
She acknowledged that most of these issues would fall into place, but in the meantime doctors were in the dark.
One of the pressing issues GPs will be focusing on now is establishing a clear pathway in and out of maternity units for their patients. That will be more complex because hospital maternity units have their own problems.
"Even though there are difficulties in general practice, it is still possible that we can get going with the service. But there are layers of difficulty in secondary care with regard to staffing, infrastructure and beds," Dr Horgan added.
A hospital source said one of the dilemmas was whether hospitals should provide a separate space for women going through the process of terminating a pregnancy; whether sensitivity requires that they should be separated from other women who may be going through miscarriages; and whether trained counsellors should be provided by the hospital to assist them with the process.
Another emerging issue concerns staff who opt not to provide abortion services, according to the source. Obstetrics teams in smaller maternity units could be seriously hampered in providing abortion services if some of their nurses or doctors chose to opt out of terminations.
The Irish Nurses and Midwives Organisation, which has not been vocal on the forthcoming roll-out of abortion services, has meanwhile been in talks with the Health Service Executive over the role of nurses in providing services.
The HSE has been working flat out to put the building blocks in place ahead of the introduction of services, conscious of the stalling effect of the Christmas holiday falling in the path of the looming deadline.
Complicating matters is the Regulation of Termination of Pregnancy Bill, which is not yet law. It was passed by the Dail last week and, with clear passage through the Seanad, it should be signed into law well before Christmas.
Draft clinical guidelines for the provision of abortion services will be circulated to medical professionals later this week - the absence of any guidelines to date has been among the biggest concerns for doctors.
Contracts for GPs who have opted in to the service are also due to be posted out ahead of the Christmas standstill.
The HSE confirmed this weekend that the 24-hour helpline and website, called MyOptions.ie, will go live on January 1, offering women non-directive counselling and clinical support. It confirmed that counsellors will man the helpline until 8pm, after which clinical staff will take over the calls.
Caredoc, the out-of-hours family doctor service, will provide the clinical helpline cover, with One Family, the lone parent group, contracted to provide pregnancy counselling.
Stocks of medications and other supplies for family planning clinics and GPs are in train, according to Dr Boylan.
The HSE has also finalised an ultrasound service as well as signing off in the last number of days a contract with a private firm, Affidea, to provide scanning services, he added. While there will not be a scanner at every crossroads, he said this weekend that all regions of the country would be covered. GPs will be given details shortly on the mechanics of how to access the scanning service.
The Department of Health has asked 19 maternity units and hospitals for updates on their plans to roll out the abortion service. It is understood that a number have indicated that they cannot commit to the January 1 start date.
It is not clear yet either how many of the country's 4,000 GPs have 'opted in' to provide abortion services. Sources have quoted a figure of around 150, with that number expected to increase as the service beds down.
Taoiseach Leo Varadkar has previously said that 50 to 60 GPs would be sufficient to provide the service, based on figures that around 12 women in Ireland a day choose to end their pregnancies, six through an abortion pill.
Simon Harris issued a statement this weekend accepting that some medical practitioners had "genuine concerns" and saying he was committed to working to address them. But he is also committed to bringing in the service in January.
Dr Boylan has also tried to quell the unease of some of his medical colleagues. The service will not be perfect, he acknowledges, but the important thing is that the deadline must be adhered to. The longer the delay, the more women who will have to travel to the UK.
Much will hinge on a high-level meeting tomorrow between the HSE and the maternity hospital masters, the Irish College of General Practitioners and the Institute of Obstetricians and Gynaecologists.