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Abstract
Introduction The provision of abortion services in the Republic of Ireland is legally restricted. Recent legislation that has been implemented allows for abortion if there is a real and substantial risk to the woman's life, but in general Irish women must travel abroad for abortion services. The aims of this study were to investigate the clinical experiences of Irish obstetric non-consultant hospital doctors (NCHDs) that work in this environment and to assess their attitudes towards termination of pregnancy (ToP).
Methods We conducted an online cross-sectional descriptive survey of 184 Irish obstetric NCHDs. Quantitate and qualitative analysis was performed.
Results There was a 28% response rate. 88% of respondents thought that ToP should be permitted for fatal fetal abnormality if the parents choose, 96% if the woman's health is severely affected and 86% in cases of rape and incest. Over 90% of respondents believed a woman's health suffers because of the need to travel abroad to undergo a ToP. Physical, psychological and social reasons were explored. The research also highlights that obstetric trainees are actively involved in the provision of preabortion and postabortion care.
Conclusions The clinical experiences and opinions of the respondents suggest that the current legal availability of abortion in Ireland is insufficient to guide best clinical practice and does not represent the views of those that provide obstetric care.
- Abortion
- Obstetrics and Gynaecology
- Interests of Woman/Fetus/Father
- Reproductive Medicine
- Maternal mortality
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- Abortion
- Obstetrics and Gynaecology
- Interests of Woman/Fetus/Father
- Reproductive Medicine
- Maternal mortality
Introduction
The provision of abortion services in the Republic of Ireland is restricted through constitutional and legislative mechanisms. Irish doctors, and practising obstetricians and gynaecologists, have expressed difficulty in the interpretation of the legal framework for the delivery of clinical care for pregnant women.1–3
Since 1861, procuring a termination of pregnancy (ToP), or assisting a woman in such a procedure, has been a criminal offence in the UK and Ireland, under the Offenses Against the Person Act. In the UK, the 1967Abortion Act saw the introduction of legal termination for a range of circumstances.4 In 1983, the Eighth Amendment of the Irish Constitution (Article 40.3.3) was passed by the Irish public, which effectively banned abortion in all situations in Ireland, guaranteeing to protect the life of the unborn and its equal right to life to the mother. In 1992, the refusal to allow a 14-year-old rape victim, who was suicidal, to travel abroad for a termination of pregnancy, by a High Court injunction, led to the well-known ‘X Case’.5 The resultant common law and two subsequent referenda in 1992 and 2002 upheld the right to abortion services in Ireland if there was a real and substantial risk to the life of the mother, including the risk of suicide. A constitutional right for Irish women to travel abroad to access abortion services was established.6 ,7 The Abortion Information Act in 1995 limited the information Irish doctors could give to women regarding abortion and prevented direct referrals for abortion services in the UK.8 No legislation or guidance for doctors to interpret this common law judgment existed until 2013.
The Irish government faced increasing pressure to legislate for situations when a doctor could terminate a pregnancy if the life of a mother was in danger, both externally from the European Court of Human Rights, and internally from the political fallout from the death of Savita Halappanavar.9 ,10 Medical opinion was divided, with consultant obstetricians and psychiatrists voicing arguments both in favour and against legislating for the provision of abortion services at government hearings.11 The Institute of Obstetricians and Gynaecologists specifically requested legal clarity from the government, and the College of Psychiatry of Ireland stated: ‘None of us has seen a woman where the only treatment that would have prevented suicide was a termination of pregnancy, emphasising the rarity of this. As proposed legislation is so narrow, floodgates are unlikely to be opened’.11 The Protection of Life During Pregnancy Act (PLDPA) was passed in 2013 permitting Irish women to obtain a ToP in Ireland in very limited circumstances, if deemed appropriate by medical professionals.12 To access abortion services under mental health grounds, the PLDPA required that one obstetrician and two psychiatrists must jointly certify that there is a substantial risk to the woman's life.12 Subsequent guidance was introduced in 2014 to help healthcare professionals interpret this legislation.13 Criticisms of both the PLDPA and guidance document came from the UN Human Rights Committee and doctors who articulated that excessive scrutiny would be placed on women by medical professionals and that women seeking abortions due to rape, incest, fatal fetal abnormality (FFA) or serious risks to health were denied.2 Twenty-six terminations were permitted under the PLDPA in 2015; 14 arising from a risk of physical illness, 9 from emergencies arising from physical illness and 3 arising from risk of suicide.14 This contrasts to the 3735 women with an Irish address who travelled to the UK for a ToP in 2014.15 The Irish Medical Council reaffirmed the obligations for doctors to maintain the equal rights of the fetus in 2016, noting doctors must ‘make every reasonable effort to protect the life and health of pregnant women and their unborn babies’.16 Providing an abortion outside of the PLDPA legislation incurs a criminal sanction of up to 14 years in prison, for both doctors and patients, which has been argued to act as a ‘chilling factor’ for Irish doctors and Irish women who take ‘illegal’ abortifacients in Ireland.2 ,12 ,17
The experiences of women who have abortion services have been difficult to research, and previous studies have examined the experiences of healthcare professionals as a reflection of women's experiences.3 ,18 The experiences of non-consultant hospital doctors (NCHDs) training in Obstetrics and Gynaecology are of particular interest as they will be working under the current PLDPA 2013 for the duration of their careers. The aims of this study were to (a) to investigate the clinical experiences of Irish obstetric NCHDs in caring for women who seek, or have had, a ToP; and (b) assess their attitudes towards ToP.
Methods
We conducted a cross-sectional descriptive survey, which provided quantitative and qualitative data. Surveymonkey.com was used to disseminate the survey via email through a representative of the Junior Obstetric and Gynaecology Society (JOGS) in January 2015. The survey instrument was designed by both study authors, aiming to answer our research questions. It comprised a mixture of 19 open and closed questions, with text boxes to elaborate responses. Questions focused on demographic information, attitudes and opinions towards ToP and clinical experiences relating to ToP. Attitudinal questions were adapted from previous peer-reviewed papers, and those with certain opinions were asked different questions to investigate their opinion further.3 ,18 The clinical questions related to the study research questions, such as the involvement of obstetric NCHDs in postabortion care and whether NCHDs felt the need to report illegal abortifacient use to the police services. The survey was piloted twice prior to dissemination with eight Irish doctors, including general practitioners (GPs) and NCHDs who had worked as obstetric NCHDs in the past. We invited all obstetric NCHDs in the country to participate; we emailed all JOGS members (n=166) as well as 18 NCHDs in the Rotunda Hospital, which is a major city centre maternity hospital in Dublin. One follow-up reminder email was sent 2 weeks later.
Data were extracted from http://www.surveymonkey.com and exported to both Microsoft Excel and STATA (V.13 for Mac) for quantitative analysis. χ2 tests were performed to compare and assess significance between categorical variables. The p value for significance was set at 0.05. The free text box responses were transcribed for qualitative analysis and underwent thematic analysis independently between the three researchers. Major themes and representative quotations were achieved by consensus.
The survey was voluntary and anonymous, providing a detailed summary document, enabling (non-written) informed consent from participants.
Results
Respondent demographics
The response rate was 28% (52/184). Eighty-six per cent of the respondents were female. The age groups (years) included ≤24 (4%), 25–29 (31%), 30–34 (43%), 35–39 (14%) and ≥40 (8%). Mean experience of respondents was 5.6 years (SD 4.1 years; range 0–20). The grade of NCHD respondents was categorised as (a) intern or senior house officer, 32% (16); registrar, 27% (13); specialist registrar, 37% (18); and consultant, 4% (2). The two consultant responses were included in this paper due to the likelihood of a recent grade change given they were still included in the JOGS mailing list. Respondent religion was categorised as Catholic, 47% (16); Muslim, 12% (6); other Christian, 8% (4); no religion, 22% (11); and other, 10% (5). We could not compare the demographics of the overall sample of obstetric NCHDs to those of the respondents.
Clinical experiences of obstetric NCHDs with abortion
Emergency terminations
Sixty-three per cent (33) were involved in the management of a woman who had an abortion indicated because of severe or life-threatening illness, which in their personal opinion was ‘for real and substantial risk to her life’. Of the 63%, 27% felt they had delayed the termination until a pregnant woman's health deteriorated further and the pregnancy was deemed a ‘real and substantial risk to the woman's life’. In total, 40 separate cases in this category were identified by obstetric NCHDs, through analysis of the open text box responses. A breakdown of the cases identified the following reasons for an emergency termination: (a) sepsis (n=23); (b) pre-eclampsia or haemolysis, elevated liver enzymes and low platelets (n=6); (c) bleeding or haemorrhage (n=4); and (d) specific maternal illness such as cancer, sickle cell disease or suicidal risk (n=7).
Information on abortion
Fifty-six per cent of obstetric NCHDs had been asked by a pregnant woman for information on abortion. Thirty-eight per cent had referred a woman to an information agency (eg, Irish Family Planning Association) for information on abortion services abroad.
Abortion provision training
Fifty-four per cent responded that they would be interested in training in abortion service provision as part of their curriculum; 30% responded ‘no’; 15% responded ‘unsure.’
Reporting an abortion to police
Seventy-four per cent of respondents would not report a woman that had taken an abortifacient, which was bought online or illegally in Ireland, to the police; 14% were unsure.
Preabortion and postabortion care
Ninety per cent of respondents previously provided follow-up care to a woman who had an abortion abroad.
Attitudes and opinions towards ToP
Opinion groups
The opinions of 50 respondents were available to analyse and are summarised in table 1, categorising them into four broad opinion groupings (A,–D). Of those respondents who had a definite opinion on abortion, 92% of respondents believe ToP should be permitted in cases of FFA, 94% (45/48) in cases of severe maternal illness, 90% (43/48) in cases of rape or incest and 85% (41/48) in cases of risk of maternal suicide.
Attitudes of obstetric non-consultant hospital doctors towards termination of pregnancy in the Republic of Ireland
No statistically significant difference in opinion was present, based on gender, age or level of training. Additionally, number of years experience was not associated with opinion groupings. Only religion was statistically significantly associated with opinion groupings, with non-Catholics more likely to be in group C (table 2).
Demographics (gender, age, grade, religion) of respondent obstetric non-consultant hospital doctors towards termination of pregnancy in the Republic of Ireland
Limited situations for acceptance of ToP
Respondents who did not agree with ToP, but believed there are certain, limited situations when ToP can be acceptable (group B), were asked to outline these situations. Of the 24 group B respondents, 92% (22) responded ‘yes’ to ToP being permitted in cases of FFA; 88% (21) responded ‘yes’ to ToP being permitted in cases of rape or incest; 96% (23) responded ‘yes’ to ToP being permitted in cases of severe maternal illness; 79% (19) responded ‘yes’ to ToP being permitted in cases of risk of maternal suicide; 58% (14) responded ‘yes’ to ToP being made available to minors.
Reasons to refuse ToP
The 22 group C respondents who believed abortion should be available on request to all women were asked to give examples of situations in which a ToP could be refused. Seven responded in a free text box; six of the seven set an upper limit of gestation at 24 weeks as the situation in which ToP could be refused, with the last person citing the case of psychiatric illness, where counselling should be offered prior to the provision of an abortion.
Health effects of travel
We asked respondents if a woman’s health suffers (physically, psychologically or socially) because of the requirement to travel abroad for a ToP. Ninety-four per cent (47) of respondents believed a woman's health suffers because of the requirement to travel abroad for a ToP (three said it didn't, none answered unsure). There was no association between respondents' opinions on abortion and their opinion about the health effects of travelling. Of the 47 respondents who thought a woman's health suffers because of the requirement to travel, 47% were in group C, 45% were in group B and 6% were in groups A and D, respectively.
A free text box was provided for respondents who answered ‘yes’ to the above question, to provide examples of how a woman's health could suffer. Twenty-two respondents brought up the possibility of physical ill-health occurring as a result of the process of travelling, which was predominantly explained by the delays in presentations if a woman had a side effect or complication. Thirty-three respondents brought up the theme of the negative psychological impact on health arising from feelings of isolation, shame and financial pressures. A smaller number made reference to the traumatic experiences of those pregnant with a FFA who chose to travel abroad for a ToP. Twenty-three respondents discussed the possibility of social ill-health, overlapping with the theme of psychological ill-health, arising from a lack of support, financial strain of the procedure and travel arrangements; and the stigma of abortion in Ireland. Table 3 provides respondent examples within each theme identified.
Free text responses for those that believed the health of a woman suffered as a result of travelling
PLDPA 2013
Forty-four per cent stated that they supported the PLDPA 2013; 36% said they do not support it and 20% were unsure. No statistically significant association between opinion on abortion and opinion of PLDPA was demonstrated; for example, of those that did support the PLDPA, 36% were in the group C opinion grouping and 50% were in the group B opinion grouping. A free text box was provided for respondents to develop their opinion on whether they supported the PLDPA or not, highlight differing reasons for not supporting the PLDPA (box 1).
Those who did and did not agree with the Protection of Life During Pregnancy Act (PLDPA) 2013
Those who support the PLDPA (only one person replied)
‘Further legislation, while not sufficient, is progress towards definitive legislation’.
Those who do not support the PLDPA
‘I support repeal of the 8th amendment’.
‘I think the bill is too vague, too narrow in its scope and creates problems as the treating physician’.
‘It does not provide sufficient guidance or direction in case of fatal fetal abnormality’.
‘There are large gaps and flaws regarding the suicide clause’.
‘Still too restrictive’.
‘I support the provision of termination of pregnancy where indicated but feel new legislation too restrictive and reject its criminalisation of doctors who provide the care to women in difficult circumstances’.
‘It actually makes it more difficult to care for women who need rapid and efficient provision of care—whether that be in a deterioration of clinical status or risk of suicide’.
Given the requirement for obstetricians to jointly certify eligibility to termination under the grounds of suicidal ideation (Section 9 PLPDA),12 ,13 we asked respondents: ‘As an obstetrician do you think you should be involved in deciding whether a woman should be allowed to undergo a ToP based upon mental health grounds?’ Fifty-six per cent (28) responded ‘yes’; 36% (18) responded ‘no’ and 8% (4) responded unsure to the question. Respondents in opinion group C were more likely to respond yes to this question and those in opinion group B were more likely to respond no (χ2=28.3; p<0.001).
Discussion
Main findings
The majority of obstetric doctors-in-training responding to our survey disagree with the current provision of abortion services in Ireland. Our results suggest that the current constitutional restriction on abortion service in Ireland limits best clinical practice, with NCHDs highlighting excessive clinical risk and possible healthcare ill-effects suffered by Irish women. Of those respondents who had a definite opinion on abortion, 92% of respondents believe ToP should be permitted in cases of FFA, 94% (45/48) in cases of severe maternal illness, 90% (43/48) in cases of rape or incest and 85% (41/48) in cases of risk of maternal suicide. Over 60% of NCHDs have been involved in the management of women who had a termination indicated because of severe or life-threatening illness. Half of these respondents had to wait for the mother's illness to deteriorate until it was deemed a real and substantial risk to the women's life. Ninety-four per cent of respondents believe a woman's health suffers because of the need to travel abroad to undergo ToP and provided physical, psychological and social reasons why this occurred. The research reveals that obstetric trainees are actively involved in the provision of preabortion and postabortion care, with >90% of respondents having provided follow-up care to a woman who had an abortion abroad. Abortifacients are taken by women illegally, in Ireland, though the exact figures are unknown.17 That some NCHDs (12%) could report such women to police authorities is an important finding, which needs consideration by legislators and postgraduate training bodies.
Strengths and limitations
We had a response rate of 28%, which may have underpowered our statistical tests and also over-represented or under-represented the sample's opinions. The demographics of the overall sample are unknown; therefore, it is unclear whether the respondent group was representative of the wider sample. We did not include nationality as an explanatory variable in our survey, which is a limitation. Given the high numbers of non-Catholics as respondents (54%) compared with the Irish public, and high numbers of non-Irish NCHDs traditionally working in the healthcare system, the attitudinal results may reflect both respondent professional experience and also an international demographic. Respondents to our survey may reflect those who possess more firmly held opinions on abortion, but the attitudinal results compare well to public opinions on abortion in Ireland.19 ,20 We used questions from peer-reviewed research papers, allowing comparisons to professional groups in Ireland.3 ,18 Another strength was our piloting process, which we believe minimised bias in the questions.
Comparisons with literature
The attitudes of Irish obstetric NCHDs are broadly similar to Irish GPs and medical students.3 ,18 Forty-four per cent of NCHD respondents support a woman's right to choose an abortion in all situations compared with 51% of Irish GPs and 55% medical students.3 ,18 Four per cent of respondents are against the provision of abortion services in any situation, slightly less than Irish GPs and medical students; 10% and 7%, respectively. Furthermore, the opinions of respondent NCHDs are similar to multiple opinion polls of the general public in Ireland from 2012 to 2016.19 ,20 A 2016 poll found that 87% of the Irish public wanted to widen the grounds for abortion and 7% were in favour of the current legal position, where abortion is allowed only when the woman's life is at risk.20 There are limited published data to compare respondent NCHD opinions with obstetricians internationally. Women in Northern Ireland do not have access to abortion services under the 1967 Abortion Act and must travel to England or Wales and pay for abortion services, like women in the Republic of Ireland.4 ,21 A 2011 Northern Irish survey of NHS gynaecologists found that 57% favoured a liberalisation of abortion laws and 78% were in favour of free abortions for women from Northern Ireland.21 ,22 In Brazil abortion is restricted to before 12 weeks gestation and for fatal fetal abnormalities, with up to 1.4 million clandestine abortions performed annually.23 A 2005 survey of Brazilian gynaecologists showed that 77% thought that abortion laws should be liberalised.23 Collectively, these studies suggest that the opinions of Irish obstetric NCHDs are similar to obstetricians in these countries with restrictive abortion laws, favouring a liberalisation of abortion laws.
Policy implications
Our study has clinical and policy implications for the Republic of Ireland. It indicates that future obstetricians in Ireland overwhelmingly do not support the current provision of abortion services, with a majority favouring abortion services in certain indications. Respondent NCHDs indicated that in some situations, where a termination is required in a pregnant woman with a serious illness, it can be common practice to delay the procedure, until a further ‘real and substantial’ risk to the mother's life develops. Though the numbers of women receiving a termination for a medical emergency under the PLDPA are low (nine registered in 2015), this has implications on the management of severely unwell pregnant women suffering sepsis, antepartum haemorrhage or pre-eclampsia.14 Professor Arulkumaran's report to the Health Service Executive (HSE), on the death of Savita Halappanavar, recommended the consideration of constitutional change to help clinicians in these situations (Recommendation 4b).9 It is known that Irish women that choose abortion suffer excessive psychological, financial and social harms, despite abortion itself being a safe procedure when readily accessible.3 ,24–26 Our results expand on this consensus, with 97% of respondents believing Irish women's health suffers as a result of travelling, this opinion being independent of their underlying opinion on abortion. Irish obstetric NCHDs are trained in the management of miscarriage and the evacuation of retained products of conception, but do not receive formal training in the direct provision of abortion services. If the Eighth Amendment was repealed and abortion services were made available to more Irish women, there would be a deficit of suitably qualified persons to provide these services. Many NCHDs indicated that they would like to train in abortion service provision, which postgraduate training bodies should address.
Future research
Further research on women directly affected by the restriction of abortion services is needed. It is known that Irish women procure illegal abortion services in Ireland, but qualitative research exploring their experiences is warranted, especially with the criminalisation in the PLDPA and the fact that some doctors may report this activity to police services.17
Conclusion
The attitudinal results of NCHDs providing obstetric care are similar to the Irish public and Irish GPs, suggesting that there is no polarisation in the abortion debate, but instead a spectrum of opinion, which broadly favours the widening of abortion services in Ireland. We believe these results are important for policymakers who need to consider the quality and safety implications identified and the effect of Ireland's constitutional restriction on abortion, created by the Eighth Amendment.
Footnotes
Competing interests None.
Ethics approval Faculty Ethics Research Committee, Trinity College Dublin.
Provenance and peer review Not commissioned; externally peer reviewed.
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