#abortiontravel Katherine Side on “Medical Abortion Use: Post-Referendum Possibilities”

This blog post is from Professor Katherine Side of Memorial University, Canada

Despite the lengthy process leading up to the May 25, 2018 referendum on Article 40.3.3 (the Eighth Amendment) of the Constitution, there is little direct discussion about medical abortion. Legal access to abortion in Ireland is long overdue, and pending a ‘repeal and replace’ vote, the Taoiseach and the Tánaiste propose a “doctor-led” protocol [1]Where doctors’ involvement provides clarity and support for medical abortion, it is likely to be welcomed. Where doctors’ involvement limits access, impinges on timeliness, and breeches privacy, it is likely to be unwelcomed. Medical paternalism, legal scholar Sally Sheldon notes, can be just as restrictive as state paternalism.

The referendum outcome could provide clear legalisation, safe practices, and expanded access. Consideration must be given to who is involved and how they’re involved in abortion. Medical abortions are safer with expanded access, not restricted access. Better health outcomes could be achieved through a state-supported model that balances access to medication and a wider range of qualified practitioners, with rights to safety, security, and privacy.

Medical abortion combines two pills, Mifepristone and misoprostal, marketed under the tradename Mifegyne©. These medications reflect current abortion practice in Ireland. They are largely responsible for decreases in surgical abortions among non-residents in the UK.[2] Illegal use of medical abortion is not a secret. Twelve presenters discussed medical abortion at the Citizen’s Assembly.[3]Professor Abigail Aiken shared research examining medical abortion use in Ireland and Northern Ireland with the Joint Oireachtas Committee.[4] People before Profit TD, Brid Smith displayed a package of medical abortion pills in the Dáil.

The Citizen’s Assembly and the Joint Committee recommend that abortion risk be defined by clinical practice. Medical abortion is included in the World Health Organization’s clinical practice guidelines for safe abortion. A growing body of evidence questions the necessity of medical supervision.[5] The reality is that medical abortion pills have been used in private Irish homes for a decade without medical supervision or negative side effects.[6]

The introduction of a doctor-led protocol for medical abortion will likely limit access. The proposed wait time of up to 72 hours between pregnancy confirmation and medical abortion access doubles domestic travel requirements and costs.[7] It lengthens an already limited window for the use of medical abortion pills.[8] Proposed reporting mechanisms involving two physicians, reporting to the Health Service Executive and the Minister of Health focus on gatekeepers, instead of on a rights-based approach to access.[9] A growing body of evidence from the United States indicates that medical supervision is often accompanied by non-medically necessary requirements (i.e. scans, tests, directive counselling, consent) that interfere with the safety of early abortions.[10]

Advocacy groups have already pioneered telemedicine access for safe medical abortion.[11]The Ethical Guidelines of the Irish Medical Council permit doctors in Ireland to practice telemedicine. [Irish Medical Council. 2016. Guide to Professional Conduct and Ethics for Registered Medical Practitioners, 8thEdition). A state-led model of telemedicine for medical abortion reduces domestic travel needs and costs. It cuts unnecessary wait times, ensures privacy, and permits early access, which enhance safety.The needs of difficult-to-access and vulnerable populations could be met by English language translation servicesthat are already included in telemedicine services;  and, telemedicine would permit state assurances about the safety of medications.

Telemedicine might appeal to some doctors.[12] It doesn’t require a significant financial investment for infrastructure and keeps operational and overhead costs low. It accommodates doctors’ urban concentration, addresses their workload issues, and offers flexible scheduling that is likely to result in fewer missed appointments.

Shared responsibilities with other specialists would benefit doctors and enhance access.[13]Allowing nurse prescribers and midwives to support medical abortion recognises their “advanced levels of practice,” promotes timely access, and better services rural health needs. And, their work as health practitioners is deemed “appropriate and safe” by independent reviewers.[14]

In exceptional circumstances, after care needs could be met by non-profit sexual health agencies, or the Health Service Executive’s Sexual Health and Crisis Pregnancy Programme. Both already provide aftercare for illegal medical abortions in Ireland. A broadly resourced, state-run, telemedicine system for medical abortion models good management practices by providing safe services with the appropriate providers, instead of relying on specialised medical experts to oversee the provision of routine, low-risk procedures.

Medically supervised locations and home-based practices are not mutually exclusive. In Sweden, France, and Great Britain, who is involved and the locations of medical abortion are combined in ways that permit flexibility and accommodate users without risking safety. This combined model could also, in the short term, accommodate hospitals that assign low priority to abortion access.[15]

The Policy Paper for the Regulation of the Termination of Pregnancy proposes that a person who procures, or seeks to procure their own abortion would not be guilty of an offence; yet it is silent about the realities of medical abortion. This silence is unlikely to change medical abortion practices in Ireland. The proposed imposition of a new regime of medical supervision may not change practices either, and it may limit opportunities for the future development of a rights-based approach to health.

 

[[1]]The Tánaiste calls for the imposition of “strict medical guidelines.”

[[2]]Under the 2013 Protection of Life During Pregnancy Act, surgical abortions in Ireland are rare.

[[3]]Not all presenters were asked requested to address abortion.

[[4]]Aiken, Abigail, Irena Digol, James Trussell and Rebecca Gomperts. 2017. “Self-Reported Outcomes and Adverse Events after Abortion through Online Telemedicine,” British Medical Journal357: 1-8. http://www.bmj.com/content/357/bmj.j2011

[[5]]Grindlay, Kate, Kathleen Lane and Daniel Grossman. 2013. “Women’s and Provider’s Experiences with Medical Abortion Provided through Telemedicine: A Qualitative Study,” Women’s Health Issues23 (2): 117-122. https://doi.org.10.1016/j.whi.2012.12.002and, Raymond, Elizabeth, Daniel Grossman, Ellen Weibe, Beverly Winikoff. 2015. “Reaching Women Where They Are: Eliminating the Initial In-Person Medical Abortion Visit,” Contraception92 (3): 190-193. https://doi.org/10/1016.j,contraception.2015.06.020

[[6]]Ngo, Thoai, Min Hae Park, Haleema Shakur, and Caroline Free. 2011. “Comparative Effectiveness, Safety and Acceptability of Medical Abortion at Home and in a Clinic: A Systemic Review,” Bulletin of World Health Organization89: 360-370. http://europepmc.org/articles/PMC3089386

[[7]]https://www.irishtimes.com/news/politics/policy-paper-to-include-time-period-between-abortion-request-and-pill-1.3417404, Department of Health.2018. Appendix 2, Policy Paper, Regulation of Termination of Pregnancy.  08 March.http://health.gov.ie/wp-content/uploads/2018/03/Policy-paper-approved-by-Goverment-8-March-2018.pdf

Research in Canada finds that those who travelled furthest to access legal domestic abortion services reported “more difficult”journeys (Sethna and Doull 2013, 53). Sethna, Christabelle and Marianne Doull. 2013. “Spatial Disparities and Travel to Freestanding Abortion Clinics in Canada,” Women’s Studies International Forum38: 152-162. http://dx.doi.org/10.1016/j.wsif.2013.02.001

[[8]]The WHO recommends use for less than 12 weeks, or 84 days; current providers provide pills in Ireland up to10 weeks gestation.

[[9]]de Londras, Fiona and Mairead Enright. Repealing the 8th” Reforming Irish Abortion Law. Bristol: Policy Press, 2018.

[[10]]Boonstra, Heather” Medication Abortion Restrictions Burden Women and Providers and Threaten U.S. Trend Towards very Early Abortion,” Guttmacher Policy Review16 (1) https://www.guttmacher.org/gpr/2013/03/medication-abortion-restrictions-burden-women-and-providers-and-threaten-us-trend-toward

[[11]]Some advocacy groups use doctors for telemedicine abortion access; others do not.

[[12]]Grindlay, Kate, Kathleen Lane and Daniel Grossman. 2013. “Women’s and Provider’s Experiences with Medical Abortion Provided through Telemedicine: A Qualitative Study,” Women’s Health Issues23 (2): 117-122. https://doi.org.10.1016/j.whi.2012.12.002

[[13]]Naughton, Corina, Jonathan Drennan, Abbey Hyde, Deirdre Allen, Kathleen O’Boyle, Patrick Felle and Michelle Butler. 2012. “An Evaluation of the Appropriateness and Safety of Nurse and Midwife Prescribing in Ireland,” Journal of Advanced Nursing69 (7): 1478-1488. https://doi-org.qe2a-proxy.mun.a/10.1111/jan.12004

[14]Naughton, Corina, Jonathan Drennan, Abbey Hyde, Deirdre Allen, Kathleen O’Boyle, Patrick Felle and Michelle Butler. 2012. “An Evaluation of the Appropriateness and Safety of Nurse and Midwife Prescribing in Ireland,” Journal of Advanced Nursing69 (7):1485. https://doi-org.qe2a-proxy.mun.a/10.1111/jan.12004

[[15]]Jones, Rebecca and Stanley Henshaw. 2002. “Mifepristone for Early Medical Abortion: Experience in France, Great Britain, and Sweden,” Perspectives of Sexual and Reproductive Health34 (3): 154-161. https://www.guttmacher.org/sites/default/files/article_files/3415402.pdf

 

#abortiontravel Katherine Side on “Medical Abortion Use: Post-Referendum Possibilities”

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