It is vital that the Oireachtas Health Committee considers the evidence and research informing the recommendations of the long-awaited abortion services review, which was published this week. As the research leads for the two key streams of the review, chaired by barrister Marie O’Shea, we hope that the findings from rigorous research will be listened to. Critically, we hope that the debate will focus on delivering excellent care to all.
Treating abortion as healthcare was a fundamental aim of the Repeal campaign. For too long, abortion had been kept separate from health. The debate focused on morality, conscience and legalities. The fact that thousands of people living in Ireland had abortions annually was repeatedly, frustratingly ignored. Abortion was often framed as something that did not happen here. Yet although the number of terminations on the island was small, abortion was very much something healthcare providers at Irish hospitals and clinics were involved in. People who got abortions saw doctors and nurses and midwives and bereavement services at Irish hospitals. Clinicians and medics could not refer directly, and there was a chilling effect of the law – but abortion, like all healthcare, is a journey, and Irish health workers were part of that journey.
To an extent, then, Ireland was ready to become a country where abortion services were locally available. But nothing can prepare a health service for such a rapid change. Repeal triggered a top-to-bottom reform in the health service. Four care pathways, involving hundreds of providers, were implemented within the first month. A fifth was added later in response to a global pandemic. An entirely new service was created within weeks. Health providers themselves took responsibility for learning how to deliver a service for which, months previously, they could potentially have been imprisoned.
Implementing post-Repeal abortion services has been challenging; the fact it happened remains astonishing. Going into the review, our job was to be independent “critical friends”. Talking to those who had abortions under Irish law, we heard women connect the referendum with wellbeing and dignity. The change in law had established women’s right to access high quality abortion care. Yet the legacy of the Eighth Amendment meant continued insecurity about provision, concerns about judgment and stigma.
The Irish model of care is innovative: GPs can provide care in the community, which women self-manage at home. But the burden of navigating complex, fragmented care pathways can be high and it falls on service users. They spoke vividly of barriers to care. Time is a key concern when seeking abortion care, but the mandatory three-day wait often becomes a four- or five-day wait. There is a risk of encountering non-providing doctors who misinterpret or do not know their responsibilities. Our data indicates that some women are still experiencing obstruction despite the obligation, enshrined in the Code of Professional Ethics, to refer to a providing doctor.
Since Repeal, people continue to travel to access abortion outside Ireland following diagnosis of foetal anomaly. The qualifying criteria for termination on these grounds in Ireland was described as rigid and involving protracted assessment. The law enacted does not always allow access to care where there are complex multiple anomalies, indicating severe life-limiting conditions. Terminations for Medical Reasons were invoked as a key basis underpinning support for Repeal, but our research shows that care is denied to many who seek it, often by sympathetic providers who fear criminal reprisals or interpret the law too conservatively. Women who spoke to us felt let down, angry and bewildered at a time of acute loss and anguish. Having to travel for care post-legalisation is devastating for women and families.
Through research with service providers, what became clear very quickly was that, while Ireland has some very committed healthcare workers, the realities of the health service expected to provide abortions needs urgent attention. As already reported, staffing, infrastructure, investment, training, and workload are big issues. They are also regularly ignored within a debate that remains focused on morality and legality. Burnout is not just a risk, but a reality, and relying on the adrenaline of repealing the Eighth is simply unacceptable five years on. A will is not a way.
What is equally clear from published work and outlined in media reports is that access is geographically uneven. The millions invested in setting up a service have not resulted in a service existing across the country. Committed providers, working in small teams, keep the service going. One person going on sick leave can mean that abortion provision no longer exists in a hospital or a whole county. Being an abortion provider is not an easy thing. Some health providers have described feeling socially isolated in the workplace and, as news bulletins have reported, facing excessive workloads without support. Hearing those accounts during the review was shocking; living them must be exhausting.
When Ireland took on the commitment to be a country that delivers abortion, it also committed to deliver excellent abortion care. Things are certainly better than before. Yet for many women who need an abortion, the new service is neither more accessible nor better than the old. Some of the reasons for that are legal, but the pressures on the health service and attitudes to abortion are also key factors. And it is not because of bad health practitioners doing bad things. Although some practitioners are potentially obstructing care with, as The Irish Times has reported, “impunity”, conscientious objection alone does not explain non-provision. The small number of health practitioners sustaining abortion provision can only do so much for so long.
As a final point, it is important to remember that slogan of 2018 – abortion is healthcare. For us that slogan works both ways. We do not just have to see abortion as part of healthcare; we need to see healthcare as part of abortion.
Dr Deirdre Duffy is Senior Lecturer in Global Social Inequalities at Lancaster University. Dr Catherine Conlon is Associate Professor in the School of Social Work and Social Policy at Trinity College Dublin