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In 2018, termination of pregnancy (TOP) was legalised in Ireland.1 Healthcare professionals expressed concern regarding the short interval between the passing of the legislation and the introduction of the service to maternity hospitals in the absence of staff training or provision of additional staffing and resources. Both the Institute of Obstetricians and Gynaecologists (IOG) and the Health Service Executive issued guidance to provide clarity on clinical pathways and medical protocols; however, it is unclear if this guidance was used or if this information was widely disseminated among clinical staff.2 ,3 An audit of the first year of early TOP services (<12 weeks gestation) in a Irish maternity hospital was conducted in order to understand the care provided, the protocols followed, and potential areas for improvement.
All cases of TOP within the hospital in 2019 were recorded in a database at the early pregnancy clinic, with data on the woman’s characteristics, details of pregnancy and details of medical care included. Data on cases relevant to the audit were extracted and recorded in an anonymous database. When required, further data on cases were obtained through a retrospective review of electronic charts.
Forty-two women underwent early TOP in this hospital (table 1); however, the care received varied in the areas of admission and medication administration timings, management of retained products, follow-up and involvement of medical professionals in care.
Significant differences in length of time until admission were recorded. On average, women were admitted 1 day 14 hours after the initial consultation but this ranged from 21 hours to almost 3 days. As a result, intervals between mifepristone and misoprostol administration also varied. Guidance states that misoprostol should be given 24–48 hours after mifepristone, as this is linked to efficacy; however, 12 women received misoprostol outside this time frame.2 In the audit, greater time periods between mifepristone and misoprostol were associated with longer hospital stay.
Inconsistent management of retained products of conception was also observed in this audit. No Irish national guidance for the management of incomplete medical TOP has been made available; however, the World Health Organization (WHO) advises use of repeat administration of misoprostol or vacuum aspiration.4 Although some women were managed in line with this guidance, eight women were given oxytocin to aid delivery of retained tissue.
A small proportion of hospital consultants participated in TOP care with two providing care for over half the cohort. While the Act allows for conscientious objection, a service run by such a small number of physicians is unsustainable.1 5 The women who presented between 11 and 12 weeks’ gestation (16/42, 38.1%) pose particular challenges as TOP must be completed prior to the 12 weeks legal limit. This can be difficult at weekends, if a participating consultant is not present in the hospital. Doctors-in-training had no routine involvement in the service but were called upon to provide emergency care.
Less than half the women received a documented review with a doctor pre-discharge and none were prescribed contraception prior to leaving hospital. The WHO and IOG guidance recommend that contraception is reviewed at this stage and prescribed where indicated.2 4
These findings reflect the difficulties faced by secondary care in adapting services, organising resources and providing training. This may ultimately lead to a gap in provision of care in these units, particularly as just 10/19 maternity hospitals in Ireland are providing comprehensive early TOP services. Going forward, it is important that there is clarity on protocols and that staff are educated about guidelines if there is to be standardised delivery of care that protects the welfare of both staff and women. The care of women seeking TOP should not be reliant on a small number of participating consultants alongside limited involvement of doctors-in-training.
The authors are grateful to Karyn Walsh for her role in data collection for the study.
Contributors KOD and SL were responsible for the study conceptualisation. EOS and NR completed data collection. EOS and SL analysed the data. EOS, KOD and SL wrote the letter.
Funding This work was supported by the Summer Undergraduate Research Experience (SURE) award, University College Cork. No grant number is associated with receipt of this award.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; internally peer reviewed.