Suggestion that abortion services could collapse ‘over the top’ and ‘unhelpful’, doctors say

Statements suggesting abortion services “could collapse” and that parts of them are “not sustainable” by a researcher involved in a review of abortion legislation are “not true”, doctors working in the service have said.

Some have described the comments by Dr Deirdre Duffy, a sociologist at Lancaster University, as “over the top”, “unhelpful”, and “just what obstructors and objectors want to see to scare women”.

Doctors said while there are “vulnerabilities” in aspects of abortion care, the service is “layering in” well since its commencement in January 2019.

Dr Duffy and researchers based in Manchester Metropolitan University were appointed by the Government to examine clinicians’ experiences providing abortion, as part of a wider review. The review, chaired by barrister Marie O’Shea, has been sent to Minister for Health Stephen Donnelly but Dr Duffy’s strand remains unpublished.

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Earlier this month she told The Irish Times she had identified a number of issues including the management of conscientious objection which she said was in some instances blocking women from accessing abortion care, geographical inequities in access to care, and uneven staffing levels in hospitals.

[ US abortion drug ruling 'a dangerous precedent', says Harris ]

“There are parts where I have real concerns that the service could collapse because it is just not sustainable in its current form. It’s a consultant-led service and there aren’t very many consultants,” she said.

Dr Aoife Mullally, consultant obstetrician at the Coombe hospital, Dublin, and national clinical lead for the Health Service Executive abortion services, said she did “not recognise a lot” of what Dr Duffy said.

Roscommon GP, Dr Madeleine Ní Dhálaigh, said to say abortion services were at risk of collapse was “over the top”. While she shares concerns about women in areas such as the northwest having access to fewer providers, and the ongoing challenges of hospitals such as Letterkenny, Co Donegal not providing abortion services, she said: “Women are getting the service. The service does need more work but no, it is definitely not on the brink of collapse.”

Ireland’s abortion services started operating in January 2019, with about 200 GPs contracted to provide medical abortions at up to nine weeks’ and six days’ gestation in the community. Abortion services for women between 10 and 12 weeks with complications, were available in six of the 19 maternity units.

As of this week there are 412 contracted providers in the community – about one in three GP practices – and in 11 maternity units. Dr Mullally is confident the service will be in 17 units by the end of the year.

While just one GP in a practice can hold the contract, there may be many in the practice providing abortion care.

Cork-based GP Dr Mary Favier said abortion care is “effectively a service of two halves”.

“From a general practice point of view the service is working well ... There is a geographic challenge, with the southwest having the strongest number of providers. In Cork we have more than enough GP providers, whereas in the northwest you could still travel 50km to get a service.”

However, the retention of telemedicine after the pandemic, to allow both GP consultations – the legislation mandates a three-day wait between seeking an abortion and getting the medication – has “been a game-changer, because it negates so many of the disadvantages whether it’s distance, disability, childcare, transport,” she adds.

“The GP service could be better, but it is robust and we are getting there. GP trainees are showing a lot of interest. We ran further training workshops recently which were very well attended, so the service is slowly layering in.”

She describes as “frustratingly slow”, however, the expansion of abortion care to all maternity units.

While all of these provide post-abortion and emergency care, GPs in the catchment areas of the eight that do not provide abortion have to send women and girls to other locations, sometimes long distances, for care they are legally entitled to.

“It is very difficult to work where there is no providing hospital,” said Dr Ní Dhálaigh. “You do need the clinical backup and if there are complications, women in Donegal have to go to [hospitals] in Sligo then or Mayo.”

[ More than 8,500 abortions carried out last year, says Donnelly ]

The main obstacle to service provision in hospitals is conscientious objection, which is permitted under the Act and in all other jurisdictions providing abortion. If no consultant in a hospital will provide the service, there is no service.

Addressing this requires the recruitment of consultants who will provide services and will work in those hospitals, which include Letterkenny, Co Donegal; St Luke’s in Kilkenny, Portiuncula in Galway; and Tipperary General in Clonmel.

When I saw the headline, I thought: ‘Really? It is going to be very hard now to be trying to set up the service down in [a rural town] and to read that stuff, when it’s not true’

—  Cork-based GP Dr Mary Favier

“Four of the units that were not providing have now recruited a consultant with the responsibility to lead a service,” said Dr Mullally. “One of them is in post and three are due to start in the next couple of months, and we have really positive engagement ongoing with three more units,” she said.

She would not name those where services are imminent, but they are understood to include Kerry and Wexford.

Crucial, she said, is that any service when it opens is “sustainable”. She has no interest in parachuting locums in to provide services in non-providing hospitals, who may be gone in six months.

“You have to work with who you have. You have to identify staff who are happy to provide the service and those staff need to be supported, and we need consultants in permanent roles to provide the service.”

The HSE has run workshops around the country, she continued, with “value-clarification sessions” where clinicians “can discuss in a really open and safe way their own values, and to try to separate those from the needs of the woman they are providing care to”.

She has seen nurses and midwives reassess their “strong feelings” about providing abortion during these workshops, and after working in units where abortion is provided. “I have seen in the Coombe, there is a lot less conscientious objection than there would have been in 2019 because the staff see that the women coming in for abortion care are the same women that had their babies in the hospital two or three years before, or accessed gynaecological care. They see this is just another part of women’s healthcare.

“A lot of the heat and a lot of the very strong feeling has gone out of it. They have realised it’s a very safe, uncomplicated process. You can bring people along with you.”

She stresses repeatedly the service is better delivered gradually and sustainably, than rushed, and the HSE wants it embedded in the community, provided from within the public hospital system – unlike in, for instance, the UK, where abortions are provided not in NHS hospitals but by private or charitable providers.

The HSE model, she said, is essential to it being “embedded as a normal, everyday part of women’s healthcare”.

This is valued by GPs such as Dr Ní Dhálaigh. The fact abortion care is provided in GP clinics, rather than stand-alone abortion clinics, is “a big, positive difference” she said, as it “destigmatises and normalises” abortion care.

Asked for her reaction to comments that the service is at risk of collapse, she said: “It undermines us, particularly given the fact we are providing a service, a very good service. We have a network of doctors – if one doctor can’t see a woman, they’ll put out a call to the network.

“Those comments would maybe scare women, and are exactly the sort of headlines that conscientious objectors and obstructors want ... to scare women.”

Dr Favier, agreeing again there were “vulnerabilities” in the system, is not worried the comments could affect the GP service. “There are loads of us and the service is robust,” she said.

In some hospitals, however, where “heroic” clinicians are providing the service “almost on their own”, the comments made by Dr Duffy could be “really demoralising”.

“I think that is not appreciated by researchers who do not work at the front line. When I saw the headline, I thought: ‘Really? It is going to be very hard now to be trying to set up the service down in [a rural town] and to read that stuff, when it’s not true’.”

“What I would hate to see happen,” said Dr Mullally, “is [that] people providing care would say, ‘I’m not going to do this any more’. It could be really off-putting. It’s not fair on the women we are working really hard to care for, and who get a good service from professionals who are very committed to providing that service.”

When contacted by The Irish Times, Dr Duffy declined to comment, saying she could not as her research had not been published.