Termination of pregnancy: Attitudes and clinical experiences of Irish GPs and GPs-in-training

Figures & data

Table I. Attitudes of GPs and GP registrars towards termination of pregnancy in the Republic of Ireland.

	Opinion groups^a
	Group A Never	Group B Limited	Group C Anyone	Group D No opinion
All (N = 325)	10% (32)	25% (82)	51% (167)	14% (44)
GPs (N = 218)	11% (24)	24% (53)	52% (113)	13% (28)
GPRs (N = 107)	8% (8)	27% (29)	51% (54)	15% (16)

^aOpinion on ToP in the Republic of Ireland:

Group A: ‘ToP should never be available to any woman’

Group B: ‘ToP should be allowed, but only in very limited circumstances (an example would be “with a real and substantial risk to the life of the mother”).’

Group C: ‘ToP should be available to any woman who chooses to have it performed.’

Group D: Those who ‘do not have a definite opinion on ToP.’

Table II. Demographics (gender, religion and age) of respondent GPs and GP registrars towards termination of pregnancy in the Republic of Ireland.

		By opinion groups^a
		Overall group (n = 325)	Group A (n = 32) Never	Group B (n = 82) Limited	Group C (n = 167) Anyone	Group D (n = 44) No opinion
Per cent female	GP	57	50	55	64	43
	GPR	74	75	72	74	75
Per cent Catholic	GP	76	88	89	69	71
	GPR	80	88	79	78	88
Per cent in each age group (GPs only)	≤ 30	1	2	1
	31–40	36	25	23	38	61
	41–50	32	29	34	32	32
	51–60	23	38	30	21	7
	≥ 60	8	8	11	8.0	0

^aSee definition of opinion groups in Table I.

Table III. Analysis of those who believe that ‘ToP should be available to a woman who chooses to have it performed (Group C)’.

Question asked:		General Practitioners (112a/113)	General Practice Registrars (54)
‘Up to what gestational age do you think ToP should be permissible?’	22–24 weeks	6% (7)	9% (5)
	20–22 weeks	2% (2)	8% (4)
	16–20 weeks	25% (28)	17% (9)
	12–16 weeks	21% (24)	40% (21)
	12 weeks	46% (51)	26% (14)
‘Are there situations in which you feel a ToP could be refused, despite a woman's choice to have one (not relating to gestational age)?’	Yes	22% (25)	78% (83)
	No	28% (15)	72% (38)

^aOne non-respondent to this question.

Table IV. Qualitative analysis of those who feel women have the right to choose a ToP (Group C), but also feel there are situations where ToP can still be refused. Four themes established (24 GPs and 15 GPRs).

Capacity

• ‘Every woman should have to undergo a mandatory counselling session, followed by three days to think over the decision.’

• ‘If a rushed decision with inadequate time for counselling regarding alternatives.’

• ‘Patient unable to give rational decision due to drugs or mental illness.’

Coercion

• ‘If on talking to a woman it is against her own moral belief and she feels pressurized by circumstances or other people.’

Disagreement with indication

• ‘Recurrent use e.g. as a form of contraception.’

• ‘If requested for foetal gender reasons.’

Procedure risk

• ‘Where doing it would pose a risk to the life of the patient’

Table V. Qualitative analysis of those who are against abortion, but also feel it can be allowed in very limited circumstances (Group B). Themes and quotes of when ToP can be performed, taken from 53 GPs and 29 GPRs.

Foetal anomalies (31 mentioned)

• ‘Anencephaly, Patau syndrome, Edward's and other syndromes incompatible with life diagnosed antenatally.’

• ‘With congenital malformation where they are not compatible with life (will die at birth or before).’

Maternal illness (45 mentioned)

• ‘To allow for administration of teratogenic medication such as chemotherapy. Very significant abuse or psychiatric cases. Where risk to mother is considered too great: e.g. pulmonary hypertension, mitral valve stenosis and other cardiac abnormalities.’

• ‘Mother's life at risk.’

Rape or incest (31 mentioned)

• ‘Pregnancy arising from sexual assault/rape.’

Qualitative analysis of those who feel a woman's health suffers specifically because of the requirement to travel overseas for ToP. Examples grouped into five themes (77 GPs and 41 GPRs).

Physical health effects from travelling

• ‘… came back from UK—saw her and transferred her to hospital with septicaemia—she died. No follow up. This occurred over 20 years ago.’

• ‘Many women do not attend for aftercare with their Irish GP as they are ashamed or embarrassed and often present too late with infection/bleeding etc.’

Psychological health effects from travelling

• ‘Stress of travelling, follow up, post op. infection. Psychological effects—dealing with abortion in aftermath, secrecy regarding planning trip.’

• ‘Emotionally, psychologically—the feeling of doing it covertly and making provision for family remaining at home.’

• ‘Poor supports afterwards as “taboo”. Increased guilt as felt doing something illegal more stressed with having to leave country at a very difficult period in life.’

• ‘The embarrassment, loneliness and secrecy attached to travel are added burdens on the expectant mother’

Social health effects from travelling (financial, isolation and family)

Finances:

• ‘Some have not travelled for financial reasons and regretted it.’

• ‘People can't always afford and have borrowed money.’

Isolation:

• ‘Burden of financial pressure often leading to having to travel alone.’

• ‘Social isolation in emotionally challenging situation.’

Family:

• ‘Social ill-health due to compromised relationship(s) with GP/friends/family due to knowledge of her having had an abortion, or compromised relationship due to the woman with-holding this knowledge from others.’

Doctor–patient relationship

• ‘Limited psychological support after TOP. Negative view of Irish healthcare as a result, leading to damaged doctor/patient relationship.’

Impairment of inter-doctor communication

• ‘Lack of follow up and medical liaison between doctors in the case of suicidal woman was a huge problem.’

• ‘Unknown clinic and clinicians in UK, lack of continuity of care.’

Table VII. Qualitative analysis of specific case examples given by GPs and GPRs. Examples of 42 GPs and 16 GPRs divided into seven themes.

Women travelling abroad with foetal anomalies for abortion • ‘A woman with two children who travelled to France to have a ToP because of severe deformities to her foetus—quite late in pregnancy and patient very traumatized after it and bleeding a lot.’

• ‘I had a lady who was diagnosed with an anencephalic foetus; she could not afford to travel to UK for a ToP.’

• ‘A colleague in practice had a patient who had to travel to England for ToP with a foetal anomaly incompatible with life—very wrong that she had to do this, does not demonstrate a caring attitude of Irish state.’

• ‘A woman had a major congenital anomaly detected at 23 weeks, incompatible with life—she already had a child and was a carer for her husband with a major chronic disease. It caused chaos that she had to leave the country and made a mockery of the law in this state.’

Asylum seekers who want to travel for ToP

• ‘Asylum seeker who was pregnant as a result of rape in her home country came to Ireland believing she would be able to have an abortion. Her status as asylum seeker precluded her from travelling abroad without permission of the Minister for Justice. She felt let down by doctors in Ireland, believing they refused to help her.’

Side effects of ToP relating to psychological symptoms of guilt, regret and depression

• ‘Most women very well post event—some suffer from regrets but appropriate counselling can alleviate same.’

• ‘One woman who had ToP at young age was haunted by guilt and depression at having had a TOP.’

Availability of abortifacients in Ireland

• ‘Patient requesting name of medicines which could be used for early ToP.... Money prohibitive to her travelling to UK for ToP—was exploring internet options.’

• ‘I have had two patients sourcing their own agents for medical abortion who presented to the surgery as “early miscarriage” requesting referral for ultrasound; significant trauma to both women relating to fear of prosecution, inappropriate expectations of outcome, for one woman there were significant complications requiring hospitalization which she initially refused as her partner was a medical professional and she feared ramifications of discovery.’

Inappropriate aftercare in Ireland

• ‘Patient admitted to hospital with anaemia and endometritis two weeks after ToP—highlights total lack of aftercare/advice and perception of inaccessibility to services in Ireland as patients often do not wish to disclose that they have had ToP.’

Importance of counselling

• ‘The issue I believe that is important is in the follow up of these patients. My experience to date leads me to believe follow up is not properly organized or patients do not follow up themselves.’

• ‘Crisis Pregnancy Programme initiative was very useful: Three free visits to GP (two before and one follow up visit after ToP slowed down the process for the patient and have her more time to consider options.’

General comments

• ‘... I personally feel I would never have an abortion and from a personal moral point of view I am completely against abortion. However in my professional role, I feel that every woman deserves the right to choose.’

• ‘I have very strong opinions as to the value of ToP: (a) I have never met a woman who regrets having a particular baby. (b) I am frequently, at least weekly, involved in patching up woman's lives who have had ToP. (c) I am discretional in my counselling style in all cases of crisis pregnancy, encouraging women to have the baby for the reasons outlined above.’

• ‘I worked in the UK for six years. At times ToP was used as a form of contraception, which I found annoying at times but I still felt it was a woman's right to choose. I have found it difficult at times since returning to Ireland, as there is such stigma and secrecy surrounding the issue. I work in a deprived area of North Dublin.’

• ‘Recent consultation for MAP. Second such consultation for that patient in one year. History of ToP X 4. Refuses regular contraception. Ethical dilemma for me.’

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