We welcome the opportunity to address the committee and to discuss the matter of clinical guidelines being prepared in light of the impending introduction of abortion services in Ireland. The Institute of Obstetricians and Gynaecologists, IOG, is the national professional and training body for obstetrics and gynaecology in Ireland. Members of the institute are drawn from all 19 maternity hospitals and units throughout the country. In April this year, the IOG set up a number of working groups to establish principles to underpin the development of guidelines for legislation for abortion services in Ireland in the event of successful repeal of the eighth amendment. More than 50 members of the institute volunteered to participate in the development of guidelines. Members have visited units in Scotland, England and Norway where abortion care is integrated into the health system. Clearly, the legislative process is not yet complete, so the IOG working groups are drafting guidelines on the basis of what has been proposed to date by the Minister of Health. Guidelines will be completed when the final legislation is passed by the Houses of the Oireachtas.
The following workstreams have been established: early pregnancy; threat to life and health of the mother; fetal medicine; conscientious objection; and staff training. I will comment on the some of the general principles that we are following. To deliver fit-for-purpose services for termination of pregnancy in Ireland, the institute recommends that services should be free to all at the point of delivery and funding for the service, as with all women’s healthcare, should be appropriately resourced and ring-fenced. International experience, supported by data, is that following legalisation of abortion services, numbers decline with the passage of time for a variety of reasons, including the removal of barriers to access and when the service includes advice on, and provision of, contraception. The IOG, therefore, strongly supports the proposals of the Joint Committee on the Eighth Amendment of the Constitution and the Minister for Health’s proposal that every effort should be made to reduce crisis pregnancies, including by the provision of free contraception.
Early pregnancy is defined as the first 12 weeks of pregnancy, that is 12 weeks after the woman’s last menstrual period and, on average, ten weeks post-conception. We have looked to the example of Scotland, a country with a similar population to Ireland, for data on termination services. In Scotland, approximately 75% of terminations are at less than nine weeks and 91% of these are medically induced. Approximately 10% require hospital attendance because of complications. We believe that Irish figures should be in line with those of Scotland.
In line with international best practice, it is proposed that early medical abortion, at less than nine weeks' pregnancy, takes place in the community. Although routine pre-termination ultrasound scanning is not recommended as mandatory in international guidelines, it is performed in most circumstances where it is readily available, and always if there are concerns about dates or ectopic pregnancy, or if the woman chooses. In Ireland, however, we are only too well aware of the well-documented infrastructural deficits in access to ultrasound in pregnancy. Introduction of a termination service without adequate scanning facilities is fraught with risk, and the IOG, therefore, recommends that appropriate and immediate investment in ultrasound is an integral element of termination services. After nine weeks, and before 12 completed weeks, it is recommended that medical termination takes place in the hospital setting due to the increased risk of complications such as bleeding. It is likely that a proportion of women will choose a surgical option for practical reasons. Risks and benefits of both methods will be explained.
The IOG recommends that a 24-7 helpline be established to help with appointments, provide reassurance, and provide information if a woman is concerned about any aspect of her care such as where to go in the case of a complication. The proposed three-day interval between the first consultation and initiating the termination is not supported by evidence; it may act as a barrier and it makes unwarranted assumptions about women’s ability to make their own decisions. There is evidence that those who request termination remain satisfied with their decision. A waiting time, if any, should be from the time of first contact with the service.
Contraceptive advice and services, including long-acting options, should be available at the time of the termination. Blood tests for anaemia, blood group and HCG, if appropriate, should be taken at the time of first consultation. It may also be appropriate to test for sexually transmitted infections in certain circumstances. On the threat to life or health of the pregnant woman, any woman whose life is at risk or where there is a serious risk to her health will be in hospital already. Since the introduction of the Protection of Life in Pregnancy Act in 2013, experience has been gained in the performance of termination in hospitals and, therefore, current practice need not alter.
Foetal medicine and termination for a lethal foetal abnormality will take place in hospitals. The medical procedures will be the same as for those performed for the risk to life or health. It is envisaged that medical management with Mifepristone and Misoprostol will treat the majority of cases.
Termination for foetal abnormality currently takes place outside the State. Diagnosis in Ireland is almost exclusively based on ultrasound. In the United States and Europe, magnetic resonance imaging, MRI, is the standard of care. It is useful in complex anomalies to confirm or exclude pathologies suggested by ultrasound. MRI results can change a diagnosis from fatal to life limiting and vice versa. The overall diagnostic accuracy of MRI is 93% compared to 68% for ultrasound. Thus, when MRI is used, further to initial ultrasound, additional information is provided in 50% of cases, the diagnosis is changed in 35% of cases, medical management is changed in 33% of cases and prognosis is changed in 20% of cases. MRI is currently only available in one maternity hospital in the country. The IOG recommends funding to expand access to foetal MRI.
The Medical Council has clear guidelines on conscientious objection. In section 49 of the current guide - I will not read it out - if a doctor has a conscientious objection to treatment then he or she has a duty to transfer care to another doctor. In an emergency there is no option but to give care. We see no reason to change these guidelines but we understand that the Medical Council is looking at them. Section 50 deals with current termination services in Ireland and will need to be updated once the legislative process relating to abortion is completed. We draw attention to the fact that the document on the professional refusal to provide abortion care on grounds of conscientious objection and European human rights jurisprudence on State obligations to guarantee women's access to legal reproductive healthcare has a human rights perspective. It states that, at a minimum, the State must ensure the adequate availability and dispersal of willing providers, prohibit institutional refusal of care, establish effective referral systems, disseminate information on legal entitlements to abortion care, impose clear limits on the legality of refusals and implement adequate monitoring oversight and enforcement mechanisms to ensure compliance with relevant regulations.
We want to be sure that the system is not set up to fail as we have seen already with other systems. On staff training, the institute has already begun organising courses for staff training on techniques not currently performed in Ireland and education on abortion care is being introduced into postgraduate training programmes for doctors. I understand that it will also be introduced into undergraduate programmes. A separate educational programme based on conscience and values is recommended for all whether directly involved in abortion care or not. Abortion care in Ireland will be a significant change for all healthcare professionals. In view of this, we recommend the establishment of an abortion providers' network to include nurses and midwives who will be integral to the delivery of woman centred care. I thank the committee and will be happy to answer questions.