As we move towards a date for a referendum on a repeal of the Eighth Amendment to the Constitution and the possible implementation of a policy of termination of pregnancy on request, a number of medical and health system issues will arise. They include the availability of prenatal ultrasound scans and the effect new regulations may have on pregnancies where there is a foetal chromosomal abnormality.
Q. Where will first trimester abortions take place?
A. There has been an understandable focus on hospitals and whether they have the capacity to offer a sufficient number of scans to women in early pregnancy. In fact evidence-based practice suggests primary care is where these medication-induced abortions should be provided. In the UK historically this has been outsourced to agencies such as the Marie Stopes organisation, often accessed following self-referral. However, primary care/ general practice is now considered by WHO and other bodies as the preferred location for abortions where the foetus is less than 12 weeks.
Q. So does that mean that every GP surgery in the country will have to be fitted with an ultrasound machine?
A. No, current practice guidelines are that terminations using medication (medical abortions) are initiated without the need for an ultrasound scan. Gestation will be calculated based on the date of a woman's last menstrual period. She will be prescribed medication, probably after a three-day cooling off time to ensure she is comfortable with her decision, and she will go home. After taking two separate types of tablets she will most likely experience a heavy period, with some cramping. She will then attend for at least one follow-up appointment for a post-termination check-up.
Q. Will maternity hospitals be involved at any point in the process?
A. In a minority of cases, yes. Medically-induced abortions are similar to natural miscarriages from a medical process perspective. Just as a minority of women who miscarry will bleed excessively or not expel all of the products of conception, a number of those who have medication-induced abortions will require gynaecological intervention in a hospital setting.
Q. Are the resources in place to allow early termination of pregnancy on request to go ahead?
A. Not yet. There is a need to provide training for GPs and ensure additional resources such as counselling are in place. But a GP-led abortion service would likely be modelled on the successful shared model of antenatal care already in place. Doctors and other primary care professionals will have to be remunerated in a way that doesn't prevent any woman from accessing a new service. And hospitals will require resources to provide for additional urgent and out-of-hours demand arising from the treatment of complications of medication-induced abortion. Provision will also have to be made to facilitate healthcare professionals who conscientiously object to early abortion on request.
If the referendum is passed it is essential that the Department of Health design a service that meets women's needs while being practical and safe. This must deliver abortion care as part of a comprehensive service which includes full sexual healthcare, the availability of counselling, fully trained staff and with robust transfer arrangements with hospitals.
Q. What about babies with abnormalities such as chromosomal disorders? Will they be affected by the availability of abortion on request?
A. It is unfortunate that the prospect of the elimination of disability has been conflated with the introduction of abortion on request. The Institute of Obstetrics and Gynaecology has clearly stated that "diagnosis of chromosomal abnormality, while technically possible, can rarely or realistically be achieved before twelve weeks."
Q. But I thought these abnormalities were readily identified by scans and blood tests?
A. While there has been significant progress in this area, no single test in medicine is completely accurate or fully diagnostic. In the case of Trisomy 21 (Down Syndrome) an ultrasound is performed, at between 11 and 14 weeks, to measure the thickness of tissue in the foetal neck. In parallel a blood test to measure free foetal DNA is carried out – this takes two weeks to complete.The combined results of the blood test and the scan will give an indication of the degree of risk of a chromosomal abnormality, but not a diagnosis. A firm diagnosis can only be made following an invasive procedure called amniocentesis, where a small tissue sample is taken from the developing placenta.