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Abstract
Background In 2018, the Irish government enacted a liberalised abortion law permitting expanded access to abortion from January 2019. A dedicated information and support service – MyOptions – was established to provide non-directive counselling and clinical advice about unplanned pregnancy. MyOptions provides contact details for abortion providers but does not make appointments for abortion-seekers. In 2020, the Abortion Rights Campaign (ARC) conducted research into Irish residents’ experiences of abortion care under the new law, including their experiences with MyOptions.
Methods Between September 2020 and March 2021, ARC administered an online survey. Qualitative data were coded using NVIVO software and analysed through thematic analysis. Quantitative data were analysed descriptively. This article analyses a subsection of these data to answer the question: What were abortion-seekers’ experiences of using MyOptions?
Results Many respondents were unaware of MyOptions before becoming pregnant. Some described MyOptions as useful and compassionate. Others noted a lack of clarity from MyOptions about the scope of its service and a lack of information on accessing abortion after 12 weeks. Respondents reported frustration that the service did not arrange appointments, explaining that having to contact general practitioners (GPs) themselves was stressful and time-consuming, as was GPs’ refusal to provide care or refer to a willing provider.
Conclusions MyOptions primarily benefits abortion-seekers whose pregnancies are under 12 weeks and who are comfortable contacting a GP themselves. The addition of an appointments booking service and guidance on how to access abortion for medical reasons and abortion after 12 weeks could improve the service.
- Abortion, Therapeutic
- Health Policy
- Patient Advocacy
- Patient Rights
- Reproductive Health
- Health Services Research
Data availability statement
Data are available upon reasonable request. The survey and its findings are available upon request.
Statistics from Altmetric.com
- Abortion, Therapeutic
- Health Policy
- Patient Advocacy
- Patient Rights
- Reproductive Health
- Health Services Research
Key messages
What is already known about this topic?
In May 2018, the Irish public voted to repeal the country’s constitutional abortion ban. The provision of abortion care was subsequently expanded and a state-run helpline called MyOptions providing information and counselling services to abortion-seekers was launched.
What this study adds
This article analyses abortion-seekers’ experiences of the MyOptions service. Half the respondents in this study reported that on becoming pregnant they did not know where to go to get an abortion, and a third said they did not know where to find information about where to get an abortion.
MyOptions provides little or no information on how to access abortion after 12 weeks, including in cases where the law permits abortion, such as pregnancies with fatal fetal anomoly or risk to the health of the pregnant person.
MyOptions does not arrange appointments for abortion-seekers, placing a burden on individuals to contact providers and creating a risk of encountering anti-choice general practitioners or rogue agencies, or ‘timing out’ of the legal window to access care.
How this study might affect research, practice or policy
This article provides recommendations on how to improve MyOptions service and how to ensure an efficient pathway to care.
Introduction
Following a referendum, the Irish government significantly expanded the scope of legal access to abortion in Ireland under the Health (Regulation of Termination of Pregnancy) (The authors refer to the law as the Health Act 2018 hereafter) Act 2018.1 ,2 3 Coming into effect on 1 January 2019, the Health Act 2018 allows for access to abortion under four conditions: on request for individuals whose pregnancy has not exceeded 12 weeks; in the case of medical emergencies; and when the pregnancy has exceeded 12 weeks but two medical practitioners affirm that there is either “a risk to the life, or of serious harm to the health” of the pregnant person or the pregnancy entails fatal fetal anomalies. Abortion services are provided at no cost under Ireland’s public health system, the Health Service Executive (HSE) (Abortion care is provided through a community-focused, general practitioner (GP)-led programme, and the Health and Safety Executive (HSE) reimburses providers for services.).
One in ten general practitioners (GPs) have registered with the HSE to provide abortion care.4 GPs may elect to provide care to their own patients without registering with the HSE. Some specialised clinics such as the Irish Family Planning Association (IFPA) or Well Woman are also registered providers. Clinical guidelines permit GPs and clinics to provide care up to 10 weeks of pregnancy, and require individuals to attend one of the 10 maternity hospitals that provide care between 10 and 12 weeks' gestation. Almost all first-trimester abortions involve the use of medication, including those between 10 and 12 weeks; surgical options are rarely offered.
A key element of abortion care provision in Ireland is MyOptions. The HSE launched MyOptions to function as a free, confidential, non-directive counselling and information service, as well as a clinical advice helpline for people undergoing early medical abortion. Given the historic context of suppressing information about abortion in Ireland – prior to 1992, Irish law prohibited the provision of information about abortion – a centralised, state-operated system like MyOptions constitutes a radical departure from established policy.
The Regulation of Information (Services Outside the State For Termination of Pregnancies) Act 19955 permitted giving information, if requested, “in a form and manner which does not advocate or promote termination of pregnancy” (Section 5a). Doctors could not give patients a direct referral to an abortion provider and were obliged to provide people seeking an abortion with information and counselling on continuation of pregnancy and adoption. Fears of criminal and professional repercussions of ‘promoting’ abortion made doctors less willing to share details of how to access abortion care, even where permissable. Activist organisations such as Abortion Support Network (ASN) and Termination for Medical Reasons (TFMR), and various London-Irish support groups longer ago, have provided information and assistance to Irish abortion-seekers to access services abroad. Evidence suggests that these organisations continue to undertake this work even after the introduction of the Health Act 2018.2 6–9
The Health Act 2018 repealed the Regulation ofInformation Act 1995 of and removed the legal obligation to discuss continuing the pregnancy or adoption (although the MyOptions website does provide this information). MyOptions gives abortion-seekers contact details for providers and removes the need for health practitioners to advertise that they provide abortion care. It does not arrange appointments for abortion-seekers. Globally, MyOptions is noteworthy as a national, state-funded and state-operated service which is not connected to an independent private healthcare provider (Compared to the UK British Pregnancy Advisory Service, US Planned Parenthood, or Colombian Profamilia.).10
MyOptions was designed to overcome two known barriers to abortion care by improving public awareness of how to obtain an abortion, and alleviating practitioner concerns about professional stigma and targeting by anti-abortion groups.11 Drawing on the results of survey research conducted by the Abortion Rights Campaign (ARC), this article argues that MyOptions does not meet these objectives.12
Methods
On 27 September 2020, ARC – a grassroots, all-volunteer group dedicated to achieving free, safe, legal and local abortion everywhere on the island of Ireland – launched an online survey to collect information about individuals’ experiences of attempting to access abortion care in Ireland, since the implementation of the Health Act 2018. The survey was open to anyone who had accessed, or attempted to access, an abortion in Ireland since the introduction of services. This article reports and expands on a subset of this research, namely survey respondents’ understanding and experiences of the MyOptions unplanned pregnancy information and support service.
The Abortion Access Research working group of ARC designed and conducted the original study (A copy of the survey is available on request.), and retained a professional social scientist to analyse the results. As an activist group outside a university, ARC sought ethical review from an independent panel of experts. Respondents completed a consent form at the beginning of the survey which explained that all data would be treated in a confidential manner. During analysis, data were screened and any potentially identifying information was removed.
The survey was translated and posted in 11 languages (English, Irish, Polish, Romanian, Lithuanian, Arabic, French, German, Spanish, Italian and Portuguese.) to maximise accessibility (Abortion Rights Campaign (ARC) made available the services of an Irish Sign Language (ISL) interpreter to assist respondents in completing the survey.) and took a convenience sampling approach. The survey was also disseminated via social media. In order to research as diverse an audience as possible, the survey was shared with over 25 activist groups, organisers and non-governmental organisations (NGOs), including migrant and Traveller groups, rural networks, student unions, disabled activists, and LGBTQ (lesbian, gay, bisexual, transgender and queer or questioning) networks. These groups were chosen in order to maximise participation by marginalised groups.
The survey used a mixed methods approach, generating both qualitative and quantitative data. All questions were optional. The denominator for each question varies as a result. The research team used quantitative data descriptively to determine the frequency of particular experiences and to identify demographic characteristics. NVivo was used to code qualitative data. The data were analysed following the principles of thematic analysis which “offers a robust, systematic way of coding qualitative data, and of using that coding to identify patterns”.13
Data were initially coded by the data analyst and independently checked by three other members of the research team. The following codes were determined: (i) awareness of MyOptions; (ii) understanding of MyOptions’ role in facilitating access to abortion; and (iii) experiences of MyOptions service. We report these codes using the thematic labels:
Knowledge and understanding of MyOptions
Experiences of contacting MyOptions
Experiences of using MyOptions as a liaison
Reported problems of MyOptions.
Public/patient involvement
Although patients were not explicitly involved in the design of the survey instrument, ARC members include past and prospective patients, as do the members of the organisations ARC consulted. ARC consulted with a range of migrant, Traveller, LGBTQ and disabled people’s groups, among others, to maximise the accessibility and representativeness of the proposed research. Feedback from group representatives informed revisions to the survey instrument.
Results
A total of 402 people responded to the survey, 388 of whom answered in English, 5 in Irish, 6 in Arabic and 3 in Polish. White Irish respondents were somewhat overrepresented (88.43% (n=289) vs 82.2% in the population); and 88.56% (n=302) were Irish Citizens, reflecting their numbers in the population. Respondents lived in 24 of the 26 counties in Ireland, with good spread across urban, rural, and small town settings. The largest single age cohort was respondents of 35 years and above (The authors do not know the age of people seeking abortion in Ireland. This information is not collected by the Department of Health. There is international literature on the average age of people seeking abortion.14). Some 141 respondents stated that they used MyOptions; therefore, the sample for this article is a subset of the wider survey.
Knowledge and understanding of MyOptions
Slightly more than half of respondents did not know where to go to get an abortion (54.04%; n=158). Almost a third said they did not know where to find information on where to get an abortion (32.24%; n=76).
The majority of respondents stated that they used ‘Google’ or ‘the internet’ to seek information, and most frequently found the MyOptions webpage and the IFPA website after their initial internet search. Respondent 1 explained how her initial lack of understanding deterred her from using MyOptions:
“I imagined MyOptions was going to give me different options available to me rather than an abortion… I really wish it had been more obvious online that you just need to call MyOptions to get a list of GPs!”
Experiences of contacting MyOptions
Nineteen participants (13.5%) were positive and grateful for the assistance they received. Respondent 2 stated:
“[The] woman on [the] end of the line was very caring and responsive, made sure to give me multiple opportunities to talk with her if I wanted to offload.”
Respondent 3 said:
“They were so professional and so very kind to me. I was so lost and alone and they helped me so much with no judgement.”
Four respondents, however, reported issues with MyOptions counsellors being ‘rude’ or ‘cold’. Respondent 4 stated:
“The first time I called the lady on the phone couldn’t have been more helpful and understanding. I rang a second time and the lady I got I felt was a bit cold. It put me off ringing again.”
Respondents reported being unable to contact the helpline because of technical issues and limited hours. Respondent 5 said:
“Not great, very long waiting time before I could speak to anyone. Their webchat service essentially doesn’t work.”
Experiences of using MyOptions as a liaison
Survey respondents had mixed experiences of using information provided by MyOptions to connect with abortion care providers. Highlighting a gap in MyOptions’ remit, Respondent 6 explained:
“When I called the MyOptions line I asked if my own GP provided abortion services. They told me she wasn’t listed, meaning she doesn’t take new patients, but that she might provide services for existing patients. The only way to find out if she would provide me with care was to call my doctor’s office and ask. I really didn’t want to ask and have them say no and then have to go back there in future… MyOptions should be able to tell you if your GP provides services for existing patients and not have patients have to ask their own GP’s receptionist a potentially difficult question at a stressful time.”
Other participants reported frustration that they had to arrange the appointment with the GP themselves, after initially believing that MyOptions would make arrangements for them. As Respondent 7 said, “I had to get someone to ring up for me. Can be intimidating to place that call.” Other respondents described how, even with contact information from MyOptions, arranging an appointment with a GP took time. “I rang 9 GP clinics before getting an appointment. This may not seem like a lot but when you are distressed and panicking, it is a lot.”
Respondent 8 reported negative experiences with GP practices that she had been referred to. This respondent had to call MyOptions again for additional contact details. They stated:
“I rang three different practices and two of the receptionists were very rude on the phone to me… I had to call MyOptions for a second time, I was extremely upset.”
These responses reveal significant limitations of the MyOptions service. Even though MyOptions only gives contact details for registered, willing providers, prospective patients have difficulty scheduling timely appointments, or any appointment at all. Patients also encounter resistance from staff such as receptionists, erecting further barriers to timely medical care.15
Reported problems with MyOptions
Almost one in five respondents whose regular GP was unwilling to provide abortion care (18.98%; n=26) said that their GP failed to refer them to someone who would. Being denied a referral had a negative impact on patients, creating “fear”, “confusion” and “unnecessary stress”. Respondent 9 said:
“Initially I went to my GP who refused to help me. Gave me no information other than a phone number and just told me to call the HSE.”
Respondent 10 stated:
“My GP would not treat me or advise me where I could procure an abortion and just told me I could find information on the HSE website myself.”
Respondents noted that MyOptions provides little if any information on access to abortion after 12 weeks. Respondent 11 who was waiting for amniocentesis test results said:
“I was worried that there might be a 24-week time limit. The girl on the phone didn’t know the answer. She looked up the legislation for me (which I had done before the call) and she read it to me. But the wording is hard to understand. I was disappointed that she didn’t know the answer to this important question.”
The Health Act 2018 permits abortion after 12 weeks in cases of fatal fetal anomaly and risk to health including mental health of the pregnant person. However, MyOptions does not cater for patients who need to navigate the Irish health system on these grounds, or access care abroad.
Discussion
Establishing and promoting a single, identifiable contact point for information about abortion reflects good health system design principles.16 17 However, the present research indicates serious limitations with the MyOptions service as a means to promote full access to abortion care in Ireland. Despite an initial promotional campaign in early 2019, residents of Ireland have minimal awareness and understanding of MyOptions, limiting its potential as an information service.
Another significant weakness is that the MyOptions website does not clearly state that people can obtain the contact details for registered abortion providers near them through this service, and then only if they call. The requirement that abortion-seekers call GPs to make appointments creates additional barriers, especially for those whose first language is not English, and for those who are deaf or hard of hearing, as booking translators takes time.
Best practice in referral supports individuals’ movement through the health system.18 Yet, MyOptions only provides partial support; it is not an appointment booking service. Individuals’ movement from first contact with MyOptions to an appointment with an abortion provider and receipt of care can be protracted. Abortion access in Ireland is geographically limited after 10 weeks and legally restricted after 12 weeks.3 The fact that MyOptions does not arrange appointments with medical practitioners means there is a risk of abortion-seekers ‘timing out’ of the legal window to access care.
The need to contact GPs directly also leaves room for anti-abortion clinicians to delay or obstruct access to care. Ireland has clear legal and professional ethics mandates requiring clinicians who decline to provide abortion care to refer patients to a different provider in a timely manner.2 However, as in other jurisdictions, care can be delayed or obstructed by individual clinicians if they refuse to provide precise, clear, and timely referral.19 20
As the data illustrate, MyOptions was not designed to provide information to people seeking abortion beyond 12 weeks or for problems with either their health or fetal health. This gap raises a further question about the usefulness of MyOptions for catering to a diverse range of abortion experiences.
Strengths and limitations
An important strength of the study is its focus on inclusiveness, as evidenced by consultation with diverse stakeholder organisations and availability of the survey in 11 of the most widely-spoken languages in Ireland. As an online survey with self-selecting respondents, however, the results of this research have limited generalisability
Conclusions and recommendations
Coupled with established international evidence, these findings point to key areas for improvement. Specifically, this research provides a strong argument for adding an appointments booking service to MyOptions. It also highlights the need for2: additional training for practitioners and administrators on respectfully interacting with abortion-seekers and3 a commitment to provide information on accessing abortion after 12 weeks. This research also points to the need to clarify the scope of MyOptions in public-facing material. Any reforms to MyOptions should involve an element of co-production with patients or representative groups, particularly those from marginalised communities who experience the steepest barriers to care. By making these improvements, the HSE can turn the idea of a centralised abortion information service into a real gateway for access.
Data availability statement
Data are available upon reasonable request. The survey and its findings are available upon request.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants. It is an independent research study carried out by the Abortion Rights Campaign, which is an advocacy group. As an activist group outside a university, the Abortion Rights Campaign sought ethical review from an independent panel of experts who sit on the Maynooth University Ethics Board, and who reviewed the survey before it was released. Approval was sought from these individuals in their individual capacities. The study was not officially approved by the Maynooth University Ethics Board as the study is not affiliated with the university. Participants gave informed consent to participate in the study before taking part.
Footnotes
Twitter @dnduffy
Contributors All authors contributed to the article. Authors AO'S, RR, and AC collected data and developed the survey. LG provided analysis of the data. DD and LG outlined the article and provided an inital draft. AO'S, RR, and AC reviewed the draft and added feedback and changes. LG is the guarantor.
Funding This research was funded by the Abortion Rights Campaign.
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; externally peer reviewed.