Ter­mi­na­tion of preg­nancy: Mile­stone

The Irish Times - - Front Page - Paul Cullen

clin­i­cal guide­lines for the pro­vi­sion of abor­tion ser­vices are set to be cir­cu­lated next week:

With just three weeks to go be­fore the planned in­tro­duc­tion of abor­tion in Ire­land, there re­mains wide­spread scep­ti­cism among health pro­fes­sion­als that the dead­line of Jan­uary 1st will be met.

The leg­is­la­tion to give ef­fect to the mea­sure still has to com­plete its pas­sage through the Oireach­tas and ques­tions about re­sources and sup­ports have still to be fully an­swered.

The thorny is­sue of con­sci­en­tious ob­jec­tion also looms large for many doc­tors, nurses and phar­ma­cists, and ex­ist­ing Med­i­cal Coun­cil eth­i­cal guide­lines govern­ing the med­i­cal pro­fes­sion will not be re­vised in time for the dead­line.

Notwith­stand­ing these con­sid­er­able doubts, the Gov­ern­ment and. in par­tic­u­lar Minister for Health Si­mon Harris, has made the pro­vi­sion of abor­tion by the start of next month an ab­so­lute pri­or­ity.

At this point, it there­fore seems likely the ser­vice will be­gin as planned in the new year.

Dr Peter Boy­lan, the for­mer mas­ter of the Na­tional Ma­ter­nity Hos­pi­tal who has been tasked by the Gov­ern­ment with or­gan­is­ing the new ser­vice, has said abor­tion will be avail­able “in some form” in all the State’s 19 ma­ter­nity units from Jan­uary, and also in the com­mu­nity through GP prac­tices.

He has, how­ever, also warned “there will be problems and no­body should ex­pect per­fec­tion” at the start.

De­spite the last-minute na­ture of the ar­range­ments, the broad out­line of how the ser­vice will op­er­ate is slowly be­com­ing ap­par­ent.

Knowl­edge gaps re­main and these will prob­a­bly not be filled in un­til af­ter the Oireach­tas passes the Health (Reg­u­la­tion of Ter­mi­na­tion of Preg­nancy) Bill and full sets of clin­i­cal guide­lines are pub­lished, but it is now pos­si­ble to sketch out the me­chan­ics of how an abor­tion ser­vice will be pro­vided in Ire­land for the first time.

So when will abor­tion be­come le­gal in Ire­land?

Abor­tion has been le­gal in spec­i­fied cir­cum­stances, such as a threat to the life of the mother, for many years but the Gov­ern­ment’s plan to al­low ter­mi­na­tions gen­er­ally in the first 12 weeks of ges­ta­tion is due to come into force on Jan­uary 1st.

Be­cause of the Christ­mas/new year break and the three-day cool­ing-off rule that will ap­ply to a woman seek­ing a ter­mi­na­tion, it is likely to be the sec­ond week of Jan­uary be­fore the first abor­tions take place un­der the new sys­tem.

Who will be en­ti­tled to a ter­mi­na­tion?

From next month, abor­tion will be avail­able on re­quest up to the 12th week of preg­nancy. This is dated from the first day of a woman’s last men­strual pe­riod.

There­after, abor­tion will be avail­able where there is a risk to a woman’s life or a risk of se­ri­ous harm to the health of the mother. Cer­ti­fi­ca­tion will be pro­vided by two doc­tors, one an ob­ste­tri­cian, and the foe­tus must not have reached vi­a­bil­ity.

Ter­mi­na­tions will also be per­mit­ted in cases of fa­tal foetal ab­nor­mal­ity, where it is con­sid­ered the foe­tus will die within a month of birth.

Early med­i­cal abor­tion, up to the first nine weeks, will be avail­able in pri­mary care, mostly in GPs’ surg­eries, but also in spe­cial­ist clin­ics such as those run by the Ir­ish Fam­ily Plan­ning As­so­ci­a­tion.

Abor­tions from nine weeks on will take place in hos­pi­tal ma­ter­nity units.

So how will a woman who wants a ter­mi­na­tion get one?

The main ac­cess to the ser­vice will be via a 24-hour “My Op­tions” helpline.

The woman will be able to choose from three op­tions: ac­cess to non-di­rec­tive coun­selling; in­for­ma­tion on how to ac­cess ser­vices; or clin­i­cal triage of com­pli­ca­tions. If she is seek­ing a ter­mi­na­tion, she will be di­rected to a provider who has opted in to the ser­vice.

In sit­u­a­tions where a woman goes to a GP surgery seek­ing a ter­mi­na­tion, the GP will pro­vide the ser­vice if he or she has opted in, or else re­fer the woman to an­other provider or to the helpline.

Opted in? What does that mean?

Only those doc­tors (or other health pro­fes­sion­als) who wish to pro­vide the ser­vice will do so, whether in a hos­pi­tal or com­mu­nity set­ting.

Women who seek a ter­mi­na­tion through the helpline will be re­ferred to GPs who have opted in, or to a hos­pi­tal ma­ter­nity unit where they will be dealt with by staff who have opted in.

So doc­tors will be able to refuse to have any­thing to do with the ser­vice?

No. The right to con­sci­en­tious ob­jec­tion is recog­nised but, in ac­cor­dance with ex­ist­ing Med­i­cal Coun­cil guide­lines, a doc­tor who refuses to treat a woman seek­ing an abor­tion should still have to trans­fer care to a col­league who will meet her needs.

In the words of the leg­is­la­tion, which ap­plies to all med­i­cal pro­fes­sion­als, “a per­son who has a con­sci­en­tious ob­jec­tion shall, as soon as may be, make such ar­range­ments for the trans­fer of care of the preg­nant woman con­cerned as may be nec­es­sary to en­able the woman to avail of the ter­mi­na­tion of preg­nancy con­cerned”.

Can the woman get a ter­mi­na­tion im­me­di­ately?

No. A three-day cool­ing-off pe­riod must elapse be­tween the ini­tial as­sess­ment and the ter­mi­na­tion to en­sure a fully con­sid­ered de­ci­sion.

Then what hap­pens?

Guide­lines have yet to be pub­lished out­lin­ing ex­actly what will hap­pen. Once the woman has given in­formed con­sent and her med­i­cal his­tory is as­sessed, the abor­tion pill, a com­bi­na­tion of two med­i­ca­tions, will be pre­scribed.

Mifepri­s­tone ends the preg­nancy by block­ing the hor­mone pro­ges­terone. Miso­pros­tol makes the womb con­tract and in­duces the loss of the preg­nancy, sim­i­lar to a mis­car­riage.

If the woman is un­der nine weeks preg­nant, she will take the first tablet af­ter the three-day cool­ing-off pe­riod, prob­a­bly in the GP’s surgery. She will be given the sec­ond tablet to take one to two days later. Miso­pros­tol causes cramps and heavy bleed­ing.

Ter­mi­na­tions over nine weeks will take place in a hos­pi­tal, where the ad­min­is­tra­tion of the two drugs will be stag­gered over one to two days while the pa­tient is clin­i­cally mon­i­tored.

Most abor­tions will be med­i­cal (us­ing pills). If a woman re­quires a sur­gi­cal ter­mi­na­tion af­ter the cool­ing-off pe­riod, she will present to the ma­ter­nity unit for the pro­ce­dure.

What about com­pli­ca­tions?

One-in-10 women who take the abor­tion pill seek med­i­cal at­ten­tion, re­search from other coun­tries shows. Those who con­tact the helpline may be re­ferred to hos­pi­tal for gy­nae­co­log­i­cal care.

Ex­ces­sive bleed­ing can oc­cur in one in ev­ery 1,000 ter­mi­na­tions but the ab­sence of bleed­ing can also be prob­lem­atic, as it may in­di­cate an ec­topic preg­nancy. The abor­tion pill does not ter­mi­nate an ec­topic preg­nancy which oc­curs out­side the womb.

How will a woman know the abor­tion pill has worked?

Re­duced bleed­ing and cramp­ing usu­ally in­di­cates the preg­nancy has ended.

The con­tin­u­a­tion of preg­nancy, and the risk of some tis­sue from the preg­nancy re­main­ing in the womb, is pos­si­ble, but not probable, af­ter a med­i­cal abor­tion. If there were any doubts, the woman’s med­i­cal prac­ti­tioner would re­fer her for an ul­tra­sound scan.

De­tailed pa­tient in­for­ma­tion leaflets will be pro­vided in ad­vance of any pro­ce­dure.

How much will the ser­vice cost?

Abor­tions will be pro­vided free, whether in a com­mu­nity or hos­pi­tal set­ting. GPs are to be paid a fee of ¤450 for the three pa­tient vis­its en­vis­aged as part of the ser­vice.

DARA MAC DÓNAILL PHO­TO­GRAPH:

Dr Peter Boy­lan, the for­mer mas­ter of the Na­tional Ma­ter­nity Hos­pi­tal, has been tasked by the Gov­ern­ment with or­gan­is­ing the State’s abor­tion ser­vice.

PHO­TO­GRAPH: GETTY IM­AGES

Two drugs, Mifepri­s­tone and Miso­pros­tol, are used in a med­i­cal abor­tion.

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