Analysis: the research involved evaluating abortion services and investigating such issues as training, workload and contentious objection
The much anticipated review of the Health (Regulation of Termination of Pregnancy) Act 2018 was published last month, along with recommendations, and is being discussed by the Joint Oireachtas Committee on Health today. The author is Senior Research Associate and co-author, alongside Dr Deirdre Duffy, of the Perspectives and Experiences of Service Providers on the Health (Regulation of Termination of Pregnancy) Act 2018 report which informed the legislative review and recommendations by barrister Marie O'Shea. The research involved an evaluation of abortion services from a service provider perspective and investigated issues such as training, workload and contentious objection.
Training and pathways to care
Our research concluded that while most pathways to care are now embedded, the pathway under Section 9, risk to health of the woman, which includes mental health, is still unclear. One participant said 'There isn't a clear pathway for how somebody should come for a termination on mental health grounds.’ (R107) Another said "there is an element of luck" involved in accessing an abortion under mental health grounds as it largely depends on the GP or psychiatrist and if they are willing to navigate that pathway. (R107).
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From RTÉ Radio 1's Drivetime, Fine Gael health spokesperon Colm Burke and Sinn Fein health spokesperson David Cullinane on the review of Ireland's abortion laws
The report found that while training for GPs has been significantly rolled out, training remains on an opt-in basis for GPs. In terms of training hospital staff, there was no formal training rolled out until 2021, two years after the introduction of the service. Until then, staff mostly learned through practice and informal information sharing from staff in other settings. One participant said, 'Trained? No. On the job learning.' (R105). Another said ‘The training only has come in this year. There was no training. It was, basically we made mistakes along the way.’ (R217)
There is a significant lack of access to surgical termination of pregnancy around the country. Only 11 out of 19 maternity hospitals in the country are providing early medical abortion. Providers in major hospitals around the country reported that there is still effectively no access to surgical termination of pregnancy due to a lack of training. ‘We haven’t looked at surgical options because I suppose the training that would be involved, we just don’t have the personnel available to take time off to go on a training course’. (R123) Our research found that most providing hospitals will only provide a surgical termination if multiple rounds of medical abortion have failed.
Workload
The already overburdened workload on hospital staff is another major concern in the report’s findings. One midwife explained that working overtime was unavoidable in her job due to the lack of abortion provision around the country. She explained that if a patient is travelling from one part of the country to another to access care, ‘there’s no point in me saying, "Can you come in at nine o clock in the morning?"… I’ll stay late, or I’ll come in on a Saturday morning... It means I have to be flexible because the access in the surrounding areas is limited.’ (R212) Those dedicated to providing care often have to work outside of their usual hours because of the time pressure with the gestational limit and to allow for patient travel.
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From RTÉ Radio 1's Drivetime, discussion on abortion review with researcher Dr. Deirdre Duffy
Similarly, GPs described workload as a major concern for the continuation of the service. One GP said: ‘Workload. I mean, my worry is that we won't be able to continue as providers, not that we don’t want to, but that it would become just too time-consuming, you know.’ (R213) GPs are able to limit the number of patients they accept by not registering as a public provider with My Options and provide to their existing patients only.
In 2022, 412 GP clinics of approximately 2,542 individual GPs in the country registered to provide abortion care. (GP clinics could include several providers in the one clinic. The HSE are unaware of the number of individual GPs which are providing.) Nearly 40% of of these 412 are not registered with My Options as a public provider. The opt-in approach to abortion care leaves limited service provision in certain parts of the country.
Conscientious objection
Health practitioners are not obliged to declare if they contentiously object to abortion and some managers are hesitant to ask their staff directly. One participant said: ‘Sometimes the way most managers find out is when there’s a complaint or when she observes maybe an abnormal behaviour.’ (R122) Waiting for a complaint is not sufficient means of determining contentious objection.
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From RTÉ Radio 1's Morning Ireland, Andrea Mulligan, Assistant Professor, Trinity School of Law, discusses research looking at conscientious objection rights
Conscientious objection means having to work around timetables with limited staff. One participant said: ‘You have to…make sure who was on, and to make sure who was a conscientious objector or not. Are the women actually going to be taken care of?’ (R209) Conscientious objection also adds to the workload of those who are willing to provide. One participant said: ‘I’m on my own. I should have a nurse with me...but she really doesn’t want a huge amount to do with the TOP [Termination of Pregnancy] service.’ (R201)
There are limitations to conscientious objection and we have found that these limitations are not fully understood or adhered to. Healthcare practitioners can only object to the administration of the abortion pill or the abortion procedure itself. They cannot object to providing any additional care to the patient. One participant described an incident where caterers did not want to serve the woman. ‘Some of the caterers didn’t want to even serve the woman but it’s only when you challenge and say, ‘Well first of all, you should not know her diagnosis. Why she’s here is none of your concern.’ (R122) Only those whose job description includes abortion service provision have the right to conscientiously object to the procedure.
There are limited repercussions for those who push the limits of conscientious objection mainly due to the shortage of staff. One participants said ‘we have no staff. We actually can’t afford to discipline the obstructors because then who is going to look after all the other women?’ (R125)
The National Women and Infants Health Programme administered funding for additional roles to ensure an expansion of termination of pregnancy services. Funding approval was conditional on the basis that the recruited personnel would provide or participate in the provision of termination of pregnancy services. Nevertheless, two settings in our research applied for funding to introduce termination of pregnancy services but resulted in appointing someone who contentiously objected to the provision of abortion. One participant stated: ‘There certainly have been people recruited to posts for termination where when they went into the job they ended up not doing that at all.’ (R125) Follow up is needed to ensure that public money allocated for a public service must result in provision of that service.
The research from this report have informed the recommendations outlined by Marie O’Shea. It is important that the findings and recommendations outlined in the legislative review are swiftly addressed to ensure women can access the care voted for in 2018. Sufficient training, staff shortages and workload are all issues which need to be addressed within the healthcare sector more generally, and to ensure the sustainability of abortion services. As the health committee deliberate the proposed recommendations, issues such as appropriate allocation of funding, workload and conscientious objection need to be addressed.
The views expressed here are those of the author and do not represent or reflect the views of RTÉ
