In the midst of the continuing shower of news from all over the world that I share with you, I’ve been collecting stories for a feature on Ireland. This is not a definitive piece, that will come from those who have been on the frontlines, but is based primarily on written information from a few key people and what has been in the media. This history describes an almost unique series of events, and one worth learning from. It’s a story of optimism winning over pessimism, of passionate positive action breaking down out-of-date barriers, and particularly of women’s personal stories, doorstep advocacy, highly visible supportive doctors and policymakers, all working with government to change the mindset of a nation and win a critical mass of support. They successfully created a sea-change in law, policy and service delivery in the blink of an eye. Edited by Marge Berer
The story in a nutshell
It took only seven months from the referendum that repealed the 8th Amendment to the Constitution in May 2018 for the law to be changed, providers trained, methods approved and ordered, and abortion services to become available officially in Ireland on 2 January 2019, free for everyone who is covered by existing schemes, such as the Maternity and Infant Care Scheme.
The events of the past year have been a phenomenal step-change for Ireland, in both a cultural and practical sense. Despite the very short time from the announcement of the referendum to the implementation of the new abortion law, the overwhelming ‘Yes’ vote in May (and subsequent support for abortion services), was the culmination of over 35 years of hard work by activists on the ground, led by women at every juncture.
In addition to a long list of women’s rights and abortion rights supporters, national and local groups and individuals, change was supported by pro-choice parliamentarians and policymakers, a wide range of legal and human rights experts, health professionals and their professional associations, pro-choice journalists and media, and a lot of supporters and solidarity from other countries too. The list would fill pages.
29 Jan 2018 – Irish Prime Minister Leo Varadkar says referendum on abortion to be held by end of May …
29 May 2018 -Health Minister Simon Harrissaysa billto change the law will be tabled before summer and sent to President by …
24 Sep 2018 -Simon Harris includes new funds for abortion bill to meet its pledges …
03 Dec 2018 – Medical staff given outside help to prepare for legalised abortion …
14 Dec 2018 -Simon Harrisannounces that a newabortionservice will be up …
It’s not often that a government announces not only exactly what it is going to do, when it comes to making safe abortion a reality, but also puts dates on it, and then makes it happen. Hats off to the Irish government, and especially Simon Harris.
The story from December 2018
In December 2018, staff from the World Health Organization and pro-choice doctors from the UK, Canada and USA were invited to come and teach Irish clinicians about doing abortions and others came to help to draft clinical standards and guidelines. The plan was to ensure that enough GPs were ready to provide legal abortions up to nine weeks of pregnancy from the beginning of January 2019. At the same time, the Department of Health asked the Health Service Executive (HSE) to make sure abortion services for 10-12 week pregnancies would be available in all 19 of the country’s maternity hospitals from January too.
The new law requires women to see a GP to request an abortion. No reasons have to be given up to 12 weeks, it’s on request. But women are required to wait for a full three days following the day of the request to actually have the abortion or be prescribed medical abortion pills. The three-day delay (make a request, wait three full days during which you go back to the doctor for the consent process, then back again to get the pills or have the abortion at the earliest on the fourth day) is the subject of much controversy. But Simon Harris had included it in a rough draft of the legislation before the referendum and felt he had to retain it, even though it is clinically unnecessary and a burdensome waste of women’s time. Pro-choice parliamentarians were angry, as they had been led to believe that women would at least get the abortion/pills on the third day and not have to wait till the fourth day. This will apparently be reconsidered at the first review of the legislation, which must take place within 3 years and hopefully a lot sooner. Let’s hope Simon Harris is listening.
GPs can provide medical abortion pills up to 9 weeks + 6 days of pregnancy (LMP). They cannot yet provide manual or electric vacuum aspiration (MVA/EVA); this will have to wait for training to be instituted. If the woman/girl wants an aspiration abortion, she must go to a participating maternity hospital for it. Women should also present direct to a maternity unit if they are between 10 and 12 weeks; if less than this, they will be sent to a GP for care.
Nurses and midwives have been consigned to counselling, advice and follow-up only, which is a real pity. (See World Health Organization guidance.) Hopefully they will be trained for early abortion provision too. Let’s hope Simon Harris is listening.
On 20 December 2018, a set of interim guidelines was issued to GPs by the Irish College of General Practitioners (ICGP); these give 44 pages of step-by-step advice on how to provide safe abortion care to women. GPs are told in the guidelines to inform every woman who chooses to have a medical abortion that there is a small failure rate. [Note: The failure rate can be reduced to almost nil in most cases with an extra dose (doses) of misoprostol. But this has not yet been included in most national protocols or guidelines.] Women must also be told that “unrestricted termination” [that is, abortion on request] cannot be provided beyond 12 weeks of pregnancy.
Girls aged 15 and under will be able to get an abortion “in exceptional circumstances” without the involvement of their parents or another adult, according to the interim guidelines. A girl who chooses not to involve an adult is required to complete an assessment. This apparently also caused concern among some doctors.
Even so, according to the Irish Independent, at least one GP in every county in Ireland was trained by 20 December 2018 to provide medical abortion pills up to nine weeks + 6 days of pregnancy. Even so, Dr Tony Cox, Medical Director of the ICGP, said the training body had written to Simon Harris to express their “concern at the lack of clarity around referral pathways” to maternity hospitals. He was also concerned whether conscientious objection was permitted. He received reassurances.
The law is signed and a website and helpline are launched
The new abortion law was signed by President Michael D Higgins on 20 December 2018.
On 22 December 2018, the HSE launched a page on its website with information on abortion services in Ireland. It is called myoptions.ie and has information on how/where to get an abortion, abortion methods and aftercare, and a free phone line for information, support and help finding an abortion provider or counselling if needed. The phone line is manned by counsellors, with the support of nurses. It will offer information on all options. It went live in the new year.
By 29 December, 162 doctors had signed up to provide abortion services. Family planning services’ doctors are also permitted to be providers. All but 30 of these doctors agreed their details could be given out by My Options to women seeking an abortion. The 30 were afraid of being targeted by anti-abortion activists. Simon Harris said this number would be enough to ensure that women did not have to go abroad to terminate a pregnancy after January 1st. That was a bit optimistic, but still, the number who signed up as providers and could be trained right away was impressive. The geographic spread of services was uneven, but there were only four counties out of more than 60 where no GP has signed up (to date) to provide the service.
A woman phoned a GP with a crisis pregnancy one minute after it was legal to do so
On 20 February, Dr Brendan O’Shea wrote in the Irish Independent: “The first call to our practice on 2 January at 9:01am, was a hesitant voice requesting an appointment regarding a crisis pregnancy.… The Irish College of General Practitioners’ women’s health programme had communicated intensely with GPs [to prepare]…
“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)…
“Putting a public patient in a room with an ultrasound for 10 minutes in a timely manner also caused cataclysmic eruptions. Ultrasound is indicated… mainly where doubt exists regarding how far on the pregnancy is, or if ectopic pregnancy is suspected. Given rigid legal time lines, 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…”
At present, I’m told, about 1 in 10 women is made to have a scan, and services are in place for this. This should lessen a lot with experience. [Note: WHO says ultrasound scans are not required on a routine basis with first trimester pregnancies. Some of this is lack of experience and confidence. However, the clinical enthusiasm for ultrasound seems to have no bounds.]
The My Options phone line staff, Dr O’Shea says, have been “compassionate, smart, effective and professional” from the start.
A read of the interim guidelines (Interim Clinical Support for Termination of Pregnancy in General Practice, 20 December 2018) tells far more about what is expected from doctors. So far, GPs are providing only medical abortion pills, not manual vacuum aspiration (MVA) abortions. Any woman who sees a GP for abortion pills who is deemed to need an ultrasound has to go to a hospital for it. Some women may need an anti-D injection too. So we’re not talking two visits to the GP before 9 weeks of pregnancy but at least three visits, maybe four – to ask for the abortion, sign the consent forms, get an ultrasound if doctor says so, and then come back for the pills. The woman must take the mifepristone pill at the GP; she can only use the misoprostol pills at home. This is not best practice. It does not allow the woman to make her own decision about when use the pills to start the abortion. It is an example of doctor control for its own sake, which even the doctors may not think is required. Let’s hope Simon Harris is listening.
Hence, Dr O’Shea continues: “Some believe an afternoon in Manchester [England] might still be more manageable… [When] it’s three visits, apart from the stress, while cold, anxious, tired and nauseated, [and] 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.”
But something else is emerging too, he says, now that dealing with unwanted pregnancy is no longer being shipped abroad: “[Lack of] knowledge about contraception is absolutely frightening – high-volume, high-risk unsafe sexual activity by men and women is clearly evident.”
Yet his conclusion is very upbeat and optimistic: “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.”
Let’s hope Simon Harris is listening. Because optimistic or not, the interim guidelines make the process of getting abortion pills for an early abortion really, really bureaucratic. Still, at least they don’t make counselling mandatory.
It’s 3 January 2019. Abortion services have been available for two days. In the first 24 hours, the My Options helpline receives some 100 phone calls.
On 3 January, the Health Service Executive warns hospitals not to restrict services to women from their catchment area. The number of maternity hospitals (out of a national total of 19) ready to provide abortions this first week is in fact lower than the nine officially said to be ready earlier. The ten others had already said they were not ready.
Then it emerges that one hospital has been telling women they can only get abortions after 9 weeks there if they are between 9 and 11 weeks of pregnancy, as a precaution to ensure that the abortion takes place well within the 12-week limit. This is reasonable but causes a lot of anger because it is an example of the negative consequences of restricting almost all abortions to 12 weeks only, still backed by criminal law.Let’s hope Simon Harris is listening.
It takes only a few days for the anti-abortion brigade to join the scene. On 4 January, seven young activists picket a GP clinic in Galway. This leads to calls for a law creating exclusion zones around medical practices offering terminations. We also learn that one or more misleading websites that try to mimic the My Options website have apparently been launched.
This same day, Mara Clarke of the Abortion Support Network (ASN) in London, which has been helping women in Ireland obtain abortions abroad, says she thinks between 600 and 700 women may still have to travel to Britain for an abortion in 2019 (or obtain abortion pills from the internet) because they are more than 12 weeks pregnant. She’s probably right. Let’s hope Simon Harris is listening.
On 5 January, disability rights campaigners raise concerns about the My Options helpline not being accessible to people who are deaf or hard-of-hearing. The HSE responded that they are working to make the phone line accessible as soon as possible.
On 7 January, it emerges that Northern Irish people seeking abortion services in the Irish Republic will have to pay €450. This is a big disappointment but not unexpected.
At the end of the first week of January 2019, the number of GPs who have agreed to provide medical abortion pills has risen to 200, representing about 5% of all GPs, with the number rising steadily. But no GPs have signed up yet in the four counties of Sligo, Leitrim, Carlow and Offaly. A report on 9 January says 217 GPs have now signed up. Dr Brendan O’Shea, quoted above, tells the Guardian that GPs hope to get rid of the three-day delay, calling it a restriction without medical reason. He expresses confidence that more colleagues will sign up as the service settles down.
It’s not settling down quite yet, but it has been only a week! The Institute of Obstetricians and Gynaecologists (IOG) holds an extraordinary general meeting on 9 January evening, however, to discuss a motion regarding “risk to the safety of patients” due to inadequate preparation for the implementation of abortion services in hospitals. The media report does not mention whether the motion is passed or not. The Chair of the Institute says on a news programme the next morning that IOG members would like to see a national coordinator appointed in the Health Service Executive to oversee the country’s abortion services.
The Times reports that people pretending to need “crisis pregnancy” advice have been using the My Options helpline to obtain the names of GPs providing abortion services. More than 40 doctors in 19 counties have apparently had their names and addresses shared on social media. Legal action will surely be taken against this. A week later, an article in the Journal argues that Ireland would be unique if the change in the law was the end of anti-abortion beliefs and activity. The article talks about a member of Sinn Fein who quit the party due to its support for abortion law reform, who is garnering large crowds to discuss a “different politics”. And discussions are going on in churches too, it seems. This Journal article, for example, had had 11,910 views when I read it.
Around the same time, mid-January, obstetrician Prof Louise Kenny, who was a high-profile medical voice during the 8th Amendment campaign, says she fears “hard cases” of women requiring abortions will keep coming to light due to an under-resourced health system and services being introduced in an unrealistic time frame. She thinks most doctors’ lack of training is making them afraid of prosecution if they take on a “hard case”. And then such a case comes to light.
An abortion is refused, but why…
In parliament, Ruth Coppinger and Brid Smith, pro-choice parliamentarians, announce that a woman has been refused an abortion by the Coombe hospital in Dublin, in spite of what they call a fatal fetal abnormality, allowed under the new law. On 17 January, in a press release, the Abortion Rights Campaign condemns this as a wrongful refusal of care, calling it “an abject failure of the legislation and the health service. Hospitals now have an obligation to provide medical care, which includes providing abortions in cases such as this. This case shows that simply changing the law was not enough.”
But take a deep breath. Here is why it happened, according to the report of a journalist who talked to the hospital: “Decisions on whether or not to provide terminations in cases of fetal anomaly should be reached by multidisciplinary teams of doctors on a consensus basis, [as] newly prepared guidelines indicate. The multidisciplinary team should be a formally constituted committee of the hospital whose decisions are documented in clinical notes, according to the guidelines from the Institute of Obstetricians and Gynaecologists. Such a team was constituted at the Coombe hospital… The treating doctors found that despite the presence of a ‘complex fetal anomaly’ they did not believe the condition affecting the fetus was likely to lead to its death either before or within 28 days of birth – as required by the new legislation on terminations in cases of fatal fetal anomaly. The team recommended a re-evaluation of the clinical condition of the fetus after four weeks.”
This caution may be down to the medical team’s lack of experience or fear of prosecution, but not necessarily. The real problem is the narrowness of the new law itself. If the guidelines say the anomaly must be “fatal at or within 28 days of delivery” then the medical team’s caution is justified even if at the same time it is a violation of the woman’s well-being. Restricting the permission for abortion to “fatal fetal anomaly” cases, not serious cases, when what may or may not be fatal is often not clear before delivery or a termination, is what needs changing, as in the great majority of countries that allow this. Let’s hope Simon Harris is listening.
On 24 January, the Abortion Rights Campaign publishes I need an abortion now on their website. It contains clear information on what is allowed and where to find an abortion. Probably, if I looked, I would find many other pro-choice websites with this information. Hopefully they all say the same thing, and the more the better, so that women seeking information and help can find it easily.
News media in other countries have also started publishing articles about the new situation. For example, in the French magazine Elle, they write: “N’ayez plus peur, je peux enfin vous aider” (“No need to be afraid anymore, I can finally help you”) on 25 January.
Dr Mary Favier, co-founder of Doctors for Choice Ireland, the only pro-choice doctors group, gives a talk at a reception in the UK’s House of Lords on 30 January 2019, in which she says that the main messages of the referendum campaign in 2018 were focused on the patient voice and the doctor voice. As one of the doctors’ groups, Doctors for Choice Ireland took part in multiple TV and radio interviews, wrote articles, and attended public meetings as part of the national campaign. They presented in parliament and actively briefed all the main political parties and representative organisations. They undertook an organised social media campaign, produced factsheets for use by activists and the media, and debunked myths. They ran an online doctor signature petition which was published as a full page in the national newspapers in the week before the vote. They also made multiple 60 second videos of doctors saying why they were voting yes, and public appearances with the Minister for Health, who was promoting the change in the law. Now, one month on, she says, the service is working and largely effective even if limited in places. There remains a lot to be done but for the first time in Irish history, she says, but most women do not need to leave Ireland to access abortion anymore, nor source abortion pills illegally via the internet.
As of 5 February, 253 GPs have signed up to provide medical abortion pills, of whom 126 are allowing their names to be given to women who contact the My Options helpline.
On 7 February, there is a conversation among members of the UK’s Voice for Choice Coalition about the negative articles in the media, especially among pro-choice journalists:
Marge Berer, International Campaign: “From where I sit, Ireland has held a citizens’ assembly, a national referendum, changed the abortion law substantially, and put a first trimester abortion service by GPs in place faster than anyone else in history that I know of, and they deserve a major prize for it.”
Mara Clarke, Abortion Support Network: “Yes, the law in Ireland has loads of problems, but it is now LAW, and I know far fewer people are travelling. We will work to fill gaps in provision, but the negative tone of the media is more than a bit suspect…”
Ann Furedi, British Pregnancy Advisory Service UK: “It’s so interesting the way these stories are framed. I think it’s pretty incredible that 126 GPs are ballsy enough to allow their names to be given out publicly as ‘abortionists’ in a country where it has been legal for just over a month. These are doctors with no experience of a service and where talk of the risk of a backlashhas been high. That 253 GPs have signed up to provide early abortion is nothing short of awesome! To put this into perspective, this means there are potentially more doctors carrying out abortions in Ireland than there are here in the UK, where women still have to attend special clinics or hospitals.I don’t want to be a ‘Pollyanna’ about this. But I am finding that contrary to the narrative that services would be impossible if doctors were allowed to use conscientious objection to opt out, and protests would shut down services, the response by GPs has been really positive. Bpas has been involved in a lot of the training and the demand has been higher than anyone anticipated. In some ways, it seems [due to] the referendum campaign, many people have become convinced that this is a vital service and to step up to deliver it. I accept that there is a massive amount of work to be done and that women’s access is nowhere near what it needs to be. However, putting into place new services is not as easy as flicking on a light switch. In England, a minor change to our regulations (allowing misoprostol to be taken at home) was agreed in December – and STILL many services that have been providing abortion for decades haven’t been able to implement this. Yet as a movement we’ve campaigned for this since 2001. The issues have been drug packaging, training, guidelines, blah blah… and yet it is just letting a women take away tablets that she previous had to administer on site. So, while I’m distressed to see some Irish women still needing to travel to England, I think we need to understand that there’s an amazing effort going on to make this work. And it is starting to!”
On 7 February, as anticipated, it is reported that legal proceedings have been issued against the operator of a bogus website, using a name similar to My Options, which is posing as the official HSE information service for women with unplanned pregnancies. The person is warned some days later that he could end up in jail if he does not comply with the court order to take down the website, as it might be misleading members of the public into thinking it provides objective counselling and information services.
On 18 February, a local councillor in Longford tells RTÉ’s News at One of shock and dismay in the town at vandalism at a busy local GP’s premises, which were covered in anti-abortion graffiti. Sigh. It seems American anti-abortion organisations have been descending on Ireland since January. In early February there is a protest outside Our Lady of Lourdes Hospital in Drogheda. Someone has opened an anti-abortion crisis centre, Gianna Care, in Dublin. Their target is couples who have had a diagnosis of fatal fetal abnormality. They reportedly wait in car parks, accost people and tell them abortion will be like rape. Obviously they have no experience of either.
The issue of exclusion zones around clinics and GP practices is now considered a pressing issue.Minister for Health Simon Harris has said the government aims to have draft exclusion zone legislation prepared by this summer. It looks like Simon Harris is listening, at least about this.
Two really, really positive news items
On 21 February, Irish GP Mark Murphy writes in the Irish Times:
“I am incredibly proud as a GP to be part of something so worthwhile and rewarding. I never thought I would be a provider of abortion services. It’s not that surprising really.Abortionwas not mentioned once in the medical curriculum when I qualified 14 years ago. It was an unspoken phenomenon, a secret reality. Before I became a GP, I never had a real conversation about abortion….
“Now, I’m one of approximately 300 GPs who has been providing abortion services to women over the past seven weeks. The Abortion Rights Campaign advocated a service that is free to all women, safe and legal. Only seven months after 1,429,981 people voted to remove the 8th Amendment, this care is imbedded in communities all over Ireland, integrated within existing GP practices, without stigma.
“When the door closes in the consultation room, we no longer say: “I am sorry, I can’t help you.” Our waiting rooms do not discriminate or divulge secrets. Most women are cared for without the need for onward referral. When they are, there is a network of committed obstetricians and nurses in hospitals, caring for them.
“Like so many of the doctors and nurses involved, I am incredibly proud to be part of this new movement. It is a privilege (and challenge) being a GP, but I have never been as professionally rewarded, as in the past seven weeks.
“One could be led to believe, reading commentaries over the past month (which did not speak to providers) that the provision of care has been poor. Far from it. We have set a world record for the implementation of a comprehensive abortion service. Indeed, we are the envy of many healthcare systems.”
And last but not least, on 3 March 2019, the ban on Ireland funding abortion services in developing countries was set aside. The Department of Foreign Affairs says it will launch a new initiative on “sexual and reproductive health and rights” in the developing world as part of the work of Irish Aid, the government’s development aid programme. I remember well a discussion I had about this with someone from Irish Aid in the long ago of the last century. Maybe the guy I talked to about it is still there and has helped to make it happen!
As of 14 March 2019, 301 GPs had become providers of abortion services.