The removal of the Eighth Amendment to the Constitution on May 25th guarantees improvements in the healthcare that can be delivered to Irish women and girls. The proposal to allow for unrestricted access to abortion up to 12 weeks has been given a clear mandate, with the Irish people voting two to one in favour.
It is reasonable to conclude that Irish general practitioners, reflecting the views of the electorate, were also largely in favour; indeed it could be argued that they will have been more likely to be pro-repeal as they provide healthcare to people who are pregnant and sometimes this involves crisis pregnancies.
General practitioners provide continuity of care from the cradle to the grave and are well aware of the current interruption in care for a patient who has a crisis pregnancy that she wishes to end. That this will now change with care being provided in Ireland is to be wholly welcomed.
The numbers of early abortions that need to be provided in Irish general practice are likely to be relatively small
There is a significant impetus nationally to provide a service as soon as possible. However, this will be constrained by the time needed to pass legislation, the time to ensure licensing of medication, and the time to establish evidence-based procedures and protocols to ensure that the highest standard of care is delivered.
Comprehensive service
Minister for Health Simon Harris has made it clear that he wishes to have abortion provision provided in general practice as part of a comprehensive reproductive and sexual health service which is likely to include contraception provision, sexual health counselling, sexually transmitted infection screening and the provision of medication abortion as appropriate.
The service will take some time to set up and appropriately resource. It is currently provided by GPs (with the exception of abortion) as a largely unstructured and poorly funded service. However, there is significant medical goodwill, validated by the size of the electoral mandate. It is reassuring that some preparatory work has been done already by many of those involved in the field, including obstetricians and general practitioners.
The numbers of early abortions that need to be provided in Irish general practice is likely to be relatively small considering the number of general practitioners, which is 2,500. It is expected about 5,000 medication abortions – using the abortion pill – will be requested annually (this is a guesstimate based on current available figures).
If every GP provided the service they would see about two cases per year on average. If just 100 GPs provided the service they would see about one case a fortnight. Many more GPs have expressed a conscientious commitment to providing a service; indeed, small working groups of general practitioners and obstetricians have this week been established in some regional areas to discuss how local provision might work in terms of referral pathways, access to ultrasound when indicated and follow-up aftercare.
It is likely a telephone support line for women accessing medication abortion in the community will be set up to provide out-of-hours support, for instance to establish if a patient who has recently had an abortion could need referral on to further care.
There will be provider training; however, it will not need to be extensive. For example, abortion medication counselling and prescription is associated with less risk than the insertion of a contraceptive coil. Training will be incorporated into the reproductive health education modules the Irish College of General Practitioners (ICGP) already delivers.
Moreover, contraception provision is considered a core competency in general practice and is one routinely achieved in GP training. Medication abortion provision will be an additional reproductive healthcare service. The ICGP has established a taskforce to look at all the issues involved in implementation. Other countries have undertaken provision by general practitioners in a community setting and countries such as Canada have already offered advice on how best to establish a service – it did so in January 2017.
Medication abortion provision up to 12 weeks in general practice is entirely achievable
The most significant issue that may limit GP provision does not relate to abortion. Rather that Irish general practice has suffered significant funding cutbacks (38 per cent) as part of emergency austerity measures and these have not yet been reversed.
The difficulties GPs currently face have made them understandably defensive about providing a new service when they are already underfunded to provide the current ones. Resourcing issues will need to be appropriately addressed as part of any new population-based reproductive health service.
Onward referral
Conscientious objection will be respected and is currently regulated by 2016 Medical Council ethical guidelines. If an individual doctor were to refuse to refer on (contrary to current guidance) that would then be a matter between him/her and the Medical Council as regulator.
Onward referral is regulated because it is understood that the balance of knowledge between doctor and patient favours the doctor and when patients are vulnerable the patient must be confident that any action by the doctor will, on balance, favour the patient and will ensure that the patient is not obstructed in their right to access a legal health procedure. This principle is well established in international law and is in the United Nations Declaration on Human Rights.
Medication abortion provision up to 12 weeks in general practice is entirely achievable. There are some challenges that must be addressed to ensure its timely and effective introduction. The Minister has expressed a strong commitment to such a service introduction, one that is clearly supported by a mandate from the Irish people.
Introducing new and additional services will inevitably bring teething problems but there is no doubt that in a year or so the services will be up and running in Irish general practice and will be a success.
Mary Favier is a GP and founding member of Doctors for Choice. She is vice-president of the Irish College of General Practitioners