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Providing new primary care services for abortion is a challenge, even if you voted ‘yes’
There is nothing new about unwanted pregnancies. The stories of Ireland’s mother and baby homes and Magdalene laundries are evidence of the failed attempts to deal with this issue in the past. More recently, in 2018 alone, over 3,000 Irish women sought termination of pregnancy in the UK, with many more ordering abortion medication online. More recently still, since the enactment of the Health (Regulation of Termination of Pregnancy) Act 2018, in January 2019, women experiencing a crisis pregnancy can ring MyOptions, a helpline that will provide contact details of a general practitioner or family planning clinic doctor, who will offer safe, effective, non-judgemental medical care, regardless of the woman’s chosen path.
Occasionally, I ask other GPs if they have signed ‘the contract’, this being the ‘contract for the provision of a termination of pregnancy service’ negotiated between the IMO and the Department of Health last year. I only ask this of people that I know well and only if the topic comes up in conversation, which it rarely does. Only GPs who have signed this contract are eligible for payment for providing this service and despite reasonable reimbursement, at present, approximately only 250 GPs have signed it. Generally, when a new contract is negotiated for GPs, it becomes a topic of conversation at all GP gatherings, but this is not the case with this one. It appears to me that apart from those GPs who actively campaigned for the provision of a termination of pregnancy (TOP) service, most GPs would rather not discuss it, regardless of their viewpoint. GPs who are providing the service are doing so quietly and often in isolation from their colleagues, making it feel as if this is a covert service that is best kept to one’s self.
I can understand the reasons for this. Fear of recrimination or adverse judgement. Fear of having one’s surgery picketed. Fear of causing offence to those who have strong moral objections. However, as a result of this silence, these GPs do not receive the support that comes from the informal sharing of dilemmas and solutions, experienced at all gatherings of GPs, where as a general rule, no topic is out of bounds.
The new legislation allows for unrestricted termination of pregnancy up to 12 weeks’ gestation. As it is now possible to provide abortion safely by medical means with no necessity to attend secondary care, provided the pregnancy is under nine weeks’ gestation, the task of carrying out the majority of these abortions falls to GPs.
As an Irish citizen, voting ‘yes’ in the abortion referendum implied that you wanted women to have access to an abortion service. As a GP, voting ‘yes’ meant that you or your colleagues could expect to be the ones providing this service. Logically, if one voted ‘yes’ to the theory, could one justify not providing the service? This is the dilemma that still faces many GPs.
For pregnancies under nine weeks’ gestation, the GP takes full responsibility for the counselling, prescribing, medical management and follow-up of the procedure. All sorts of scenarios present themselves. Young and older women, alone or accompanied. Women who already have children and those who do not. Women who will want children some day, but not now, and those who will never want children. Women with pregnancies under 12 weeks’ gestation and some who are unexpectedly more advanced. Women who are frightened and uncertain and women who are one hundred per cent confident in their decision.
Women with complex medical and surgical problems who require detailed history-taking because they are not our patients and do not have their medical records.
These consultations stretch us clinically and emotionally as we maintain clinical knowledge, listen in non-judgemental acceptance, regulate our conflicting emotions, and make ourselves accessible for the inevitable situations where things do not go to plan. This is not an easy task, but for those of us who voted ‘yes’, it is an inevitable consequence of our actions.
Some GPs who have not signed the contract do not necessarily have ethical objections, but they know the level of commitment required to take on this additional service. They worry about the length of the consultations in an already over-booked week. They worry that they will be inundated if they are the only one offering the service in an area. They worry that they will be unable to remain impartial and non-judgemental. They are concerned that they will offend the other doctors and staff in the practice, who may have different views. These are all valid concerns.
Non-judgemental, impartial presence is something we offer our patients every day. Perhaps it is time to do the same for our colleagues and start a conversation about how we are all coping. There may be nothing new about unwanted pregnancies, but this is a new service with novel challenges for GPs.
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I would like to help with questions that GPs may have about signing up to provide this service to their own patients, from the perspective of an Irish trained GP who does provide this service.
What about needing gynae experience?
It requires similar medical knowledge and expertise to conservatively managing a miscarriage. All GPs are capable of this.
What about the time for the consultations?
The consultation takes about the same length of time as that of most first antenatal consultations with dating, examination, discussion, information and blood forms.
What about how many consultations?
The high end of estimates for abortion rate in is about 7,000 per year (1). There are 2,500 GPS in Ireland, of whom 240 have signed up to provide this service (2), (3).
This means that if you sign up now, you are likely to see 2.4 patients per month.
Bearing in mind that these are not *extra* consultations, because people with crisis pregnancy consultations still often see their GP.
If the numbers of GPs who sign up to provide doubles to 500, then you will see about one per month for a MTOP.
If you decide to sign up to see only your own patients, you would expect to see between 2 and 3 MTOP consultations per year.
Bear in mind that these are not *extra* consultations, because people with crisis pregnancy consultations still often see their GP.
Between 2 to 30 consultations per year, depending on what level you decide to do, is a reasonable and achievable service to provide your patients.
1. Council of Europe estimation of abortion rate in Irish women of 7.8/1000, compared with HSE figures of 3.9/1000.
3. START Doctors https://startireland.ie/