Experiences of the Irish model of community medical abortion: adherence to self-managed, people-centred abortion care

ABSTRACT

The Irish abortion model of care, implemented in January 2019, is distinctive for being located primarily in the community and relying principally on medical abortion outside a clinical setting. The model facilitated mapping onto existing healthcare structures and thereby allowed abortion provision to commence quickly after Repeal of the 8th Amendment. This article considers the operation of the Irish model of abortion care under 12 weeks gestation which has been characterised as a community medical abortion model. It draws on data gathered through 46 in-depth interviews with people accessing abortion care under twelve weeks gestation between December 2019 and April 2021. These qualitative accounts of experiences of first-trimester abortion care portray what the Irish model of care entails in practice from the abortion seeker perspective. The community model of medical abortion is portrayed as involving a hybrid of self-managing abortion outside of clinical settings in the context of legally regulated provision of medication delivered through a network of community-based primary care doctors. The Irish model of care anticipated a significant shift in how self-management of medical abortion is viewed by the World Health Organization whose 2022 updated abortion guidelines included self-management of medical abortion for the first time as a fully recommended model of abortion care. The paper considers how the Irish model of community medical abortion relates to self-managed and people-centred abortion care and whether this hybrid model facilitates or circumscribes these features.

KEYWORDS:

• Abortion
• self-managed abortion
• medical abortion
• Repeal the 8th
• Ireland abortion

Introduction

Legislation enacted in Ireland following Repeal of the 8th Amendment allowed for abortion under 12 weeks’ gestation without restriction as to grounds under s.12 of the Health (Regulation of Termination of Pregnancy) Act 2018. It was anticipated, correctly, that most people seeking abortion would do so under this section of the Act and a key decision was what model of abortion care to implement (Department of Health, 2021, 2022). The Irish health service previously had only minimal experience of termination of pregnancy confined to instances of direct threat to life. Following Repeal, the Department of Health and the Health Service Executive (HSE) worked closely with primary and secondary care Clinicians to design a model of abortion care for implementation within a seven-month timeframe (Mishtal et al., 2022; Mullally et al., 2020).

For abortions in the first trimester, the model of care implemented centres on providing MA in primary care through General Practitioners (GPs) and Women’s Health Clinics (WHCs). Mishtal et al. (2022) characterise it as an Irish community model for Medical Abortion representing an innovative example of the implementation of an abortion service via primary care. A qualitative study of women’s experiences of this model of care (Conlon, Antosik-Parsons, & Butler, 2022) provides a detailed insight into its operation. The paper considers self-managed abortion both in the activist context and in the regulated health context. The analysis portrays how abortion self-management is experienced in the regulated Irish community medical abortion model asking if the dimensions of self-managed abortion and people-centred abortion care – dignity, autonomy and self-determination, equality, confidentiality, communication, social support, supportive care, compassion, solidarity and trust (Pizzarossa & Nandagiri, 2021; WHO, 2022; and Altshuler & Whaley, 2018) – carry through or are circumscribed under the Irish model.

Irish community model of medical abortion care

Under the Irish community model of Medical Abortion (MA) care, primary care GPs and doctors in WHCs provide medical abortion up to nine completed weeks’ gestation (69 days). People are referred to hospitals for care if clinically indicated, but otherwise, their full care pathway can be completed in the community. Between 10- and 12-week gestation, people are referred to hospitals for either medical or surgical abortions within a secondary clinical setting. The time-limits of 9 weeks for community-provided care are clinical decisions set down by the Care Guidelines devised by the Irish Institute of Obstetricians and Gynaecologists rather than proscribed by law. Abortion care is provided universally without charge for those accessing care with a Personal Public Service Number (PPSN) but people seeking care who are not part of the Irish social insurance system are not provided for.

The model of care involves two face-to-face consultations with a doctor separated by a legally mandated three-day waiting period specific to abortion care. At the first consult, the pregnancy is dated by the doctor based on self-reported menstrual history and clinical examination. If the pregnancy cannot be accurately dated according to the clinician, the person is referred for an ultrasound at an abortion-providing hospital or a private scanning service contracted by the Health Service Executive (HSE).

After a minimum of three-day wait, they attend a second consultation when they can consent to medical abortion. The model of care anticipates that the first medication (mifepristone) is taken in the presence of the doctor. The second medication (misoprostol) is taken at home 24–48 hours later. People may be provided with an additional dose of misoprostol to take in the event that the first dose is insufficient. They are provided with detailed guidance on self-managing the abortion by their doctor along with standardised accompanying literature prepared by the HSE, also available online.

A low-sensitivity pregnancy test is provided to self-administer two weeks after the medical abortion, to determine if the abortion has been completed. The model of care also includes an optional third consultation for follow-up care two weeks post-abortion and referral to additional services, e.g. family planning or counselling. If a person does not attend the third consultation, the doctor usually contacts them to confirm they are no longer pregnant. Early data indicates that community-based MA has been safe and effective in Ireland (Horgan, Thompson, Harte, & Gee, 2021; Spillane, Taylor, Henchion, Venables, & Conlon, 2021). Service statistics published annually by the Department of Health indicate that 98% of terminations under the law take place under s.12 of the Act (Department of Health, 2021, 2022). The data are not reported at a level of detail necessary to know the proportion of abortions that take place fully in the community, but it is estimated that this represents the majority of terminations under s.12 of the Act.

To support the community care pathway the HSE implemented a telephone helpline, My Options, for the abortion service staffed by counsellors with three components – information on providers, counselling and medical advice. The helpline provides information on abortion providers local to the person seeking care. GPs do not usually make it known otherwise that they are providing abortion care. Indeed, some GPs opt not to be included in the list of providers given out by My Options but confine provision to their own patients who initiate a request for care. By 2023, 5 years into the service about 10% of GPs contracted to the HSE have taken up the contract to provide abortion care and just under 40% of those do not opt to be on the My Options list (Duffy, Grimes, Jay, & Callan, 2023).¹ My Options helpline can also refer someone for face-to-face counselling with funded services. My Options runs six days a week. A nursing helpline providing medical support relating to abortion is also offered by My Options helpline operating on a 24/7 basis. The nursing helpline answers questions people have while self-managing medical abortion and any questions arising post termination. A translation service is available to all helpline users whose first language is not English if needed. Mishtal et al. (2022) characterise MyOptions as the key structural facilitator making abortion accessible through a single, centralised portal of entry for accessing care anywhere in Ireland.

Following the onset of Covid-19 public health measures, the HSE moved quickly and implemented a remote model of care for the abortion service allowing one or both consultations to be held virtually using telemedicine with each provider arranging modes for supplying the medication including collection or courier delivery.

Thus, the Irish model of abortion care involves legally regulated abortion offered in community settings wherein self-administration of medical abortion is anticipated to take place outside the clinical setting or ‘at home’. This paper analyses qualitative interview data with 46 women accessing abortion under this model to explore how the Irish community model of abortion care relates to the concept of self-managed abortion.

Conceptualising self-managed abortion

Medication Abortion was clinically developed in the form of mifepristone in the 1980s and first licenced in France in 1988 followed by other European countries and China initially before more widespread globally licencing (Creinin, 2000). The application of misoprostol for pregnancy termination emerged in grassroots Brazilian abortion advocacy organisations and from there spread through abortion advocacy networks as a means of locally accessible termination in many contexts globally where abortion was legally prohibited or restricted (Moseson, Herold, Filippa, Barr-Walker, & Gerdts, 2020). Medication abortion has been central to recent abortion activism wherein informal networks of abortion provision engage in collective action to provide self-managed abortion care outside of formal health services in contexts where it is illegal or limited in accessibility. Pizzarossa and Nandagiri (2021) conceptualise self-management of abortion:

as consisting of a range of individual activities–a multiplicity of behaviours and navigations that surround abortion self-use (e.g. self-sourcing, potentially necessitating (unpaid) leave from work, arranging childcare and management of symptoms or complications, confirmation of abortion), and the collective dimension that enables safe self-use through a constellation of actors and interlocutors (e.g. friends, partners, family members, community health intermediaries, pharmacists, activists, non-profit organisations, hotline operators, accompaniment networks, doulas) who undertake a number of activities (e.g. provision of accurate information, sourcing of pills, accompaniment through the process, child-care provision) to support peoples’ SMA [Self-Managed Abortion] trajectories. (p. 24)

In implementing a community model of medical abortion in 2019, the Irish model anticipated a significant shift in how self-management of medical abortion is viewed. The World Health Organisation updated abortion guidelines in 2022 consolidating current evidence and best practice for the provision of quality abortion care and for the first time self-managed medical abortion is included as a fully recommended model of abortion care (WHO, 2022). The Guidelines refer to self-managed medical abortion as when a person performs their own abortion using a specified medical regimen outside of a clinical setting. They note that self-management can refer to the entire process of medical abortion or one or more of its component steps, such as self-assessment of eligibility for medical abortion, self-administration of medicines without the direct supervision of a health worker, and self-assessment of the success of the abortion process. The Guidelines (WHO, 2022) state that all individuals engaging in self-management of medical abortion must have access to accurate information, quality-assured medicines including for pain management, the support of trained health workers and access to a healthcare facility and referral services if they need or desire it. Gerdts, Bell, Shankar, Jayaweera, and Owobabi (2022) argue that guidelines recommending self-management of medical abortion as a model of care has the potential to transform abortion access if international bodies, governments, and health systems expand the availability of abortion pills and access to trained support.

Self-management is posited as a potentially empowering and active extension of the health system and task-sharing approaches stating ‘self-assessment and self-management approaches can be empowering for women and help to triage care, leading to a more woman-centred [approach] and more optimal use of health resources’ (WHO, 2022, p. 98). They specify that it should be the individual (i.e. the ‘self’) who drives the process of deciding which aspects of the abortion care will be self-managed and which aspects will be supported or provided by trained health workers or in a healthcare facility. A supportive enabling environment is equally applicable to self-management approaches as it is to other elements of care provision according to the Guidelines. Self-management should not be considered either a ‘last resort’ option or a substitute for a non-functioning health system (WHO, 2022, p. 98). Assis and Erdman (2022) argue that in all its diversity, SMA activism is rooted in practices of collective and self-care, and values of self-determination, compassion, and solidarity (p. 2236). Altshuler and Whaley (2018) identify dignity, autonomy, equality, confidentiality, communication, social support, supportive care, and trust as features of people-centred abortion care. In this analysis, of how abortion self-management is experienced in the regulated Irish community medical abortion, we ask if these carry through or are circumscribed under the Irish model.

Methods

The Unplanned Pregnancy and Abortion Care (UnPAC) study researched service user experiences of Irish abortion care between 2019 and 2021 using a Grounded Theory (GT) approach (Conlon et al., 2022). GT involves taking a maximally open approach to generating empirical data and privileges empirical data in constructing an analytical framework over existing theories or frameworks. The method involves simultaneous data collection and analysis. Early analysis directs the focus for further data generation to deepen insights and test explanations being proposed (Conlon, 2020). People using unplanned pregnancy and abortion care services between December 2019 and August 2021 were recruited to the UnPAC study. Services comprising GPs, Women’s Health Clinics, Crisis Pregnancy Counselling Services and Hospitals disseminated Invitations to Take Part and Participant Information Leaflets to people attending these services. Those considering taking part returned a Consent to be Contacted form to the research team who contacted them after a minimum of seven days to invite them for an interview. As fieldwork spanned Covid-19 lockdown periods, remote interviewing was offered. The study was granted ethical approval from Trinity College Dublin and three clinical sites where fieldwork was conducted.

The dataset for the UnPAC study comprised 58 semi-structured face-to-face (n = 9) and remote (n = 49) interviews lasting in the region of one hour. All interviews were audio recorded, transcribed and pseudonymised. Interviewing began early in the research process and analysis began from the first interview. The semi-structured interview schedule evolved to integrate emerging insights pursuant to the method’s concern to theoretically sample for nascent concepts as data collection proceeds.

For analysis, anonymised transcripts were uploaded to NVivo qualitative software and coded following the analysis procedures set out by Charmaz (2014). As data analysis progressed and codes became more established and filled out, they were synthesised, compared and contrasted to develop abstract categories that elevated codes to explanatory processes. Categories were conceptually developed and integrated by continually checking them against the empirical data generated in the study to validate and refine interpretation to the point where understanding was saturated, indicated by reaching the point where no new insights were emerging. In this method, conceptual saturation, when no new categories are generated from the interrogation of the data, signals conclusion of the project. Analysis here presents experiential accounts of the community model of medical abortion in Ireland which 46 of 58 study participants had used and relates their experiences to the components of self-managed, people-centred abortion set out above.

Experiences of Irish community model of medical abortion

Formal information and medical supports

My Options helpline provided by the HSE is a key resource for information on abortion services. Many in the study used My Options reached through an internet search engine and were reassured of its legitimacy and validation when they noted the HSE as the service host. The website was described as well laid out with sufficient information to meet people’s needs about what abortion care entailed but provider details could only be accessed by calling the Helpline. Stigma attaching to abortion made some hesitant about calling while there was also some suspicion that the statutory helpline would, as Fiona described, try to change my mind. Experiences of using My Options were overwhelmingly positive depicting it as straightforward, caring, sensitive, helpful, understanding, and well-informed.

I was pleasantly surprised at how straightforward and how caring it was. The people that I spoke to were very sensitive and helpful … it felt like someone who had time to listen and who had training and understanding of who might be calling. (Áine)

The telephone format was considered safer than face-to-face with less risk of feeling judged while the counselling-informed approach was appreciated. As Katherine described it’s not them putting words in your mouth or questioning you, why you’re calling them or why you’re doing this. It was them asking you how you actually feel. Accessing contact details for a provider was the key value of My Options. People discerned the role of My Options as guarding information on GPs who are abortion providers. For some non-availability of an ‘open list’ of providing GPs impeded accessing care but others accepted this as a consequence of contestation over the service.

My Options’ practice is to ask people where they live and to connect them to the nearest GP provider geographically and/or most accessible based on their transport options. As there are a limited number of providers, women often found they could not be given multiple, or sometimes any, contact details of providers in their immediate area. As Helen described [My Options] knew, the minute I said which county I lived in, they were able to say straight away that there is only one GP who is a provider here. My Options can establish whether the person’s own GP is a provider so they have the option of attending them: [My Options] actually were able to check for local GPs that were with the service and it actually included my GP anyway. So they were like “oh you just contact her”. So, I contacted her to give me a call back and she was amazing. [Tanya]

My Options helped women establish their gestation and advised them on the timelines governing regulation of abortion to ensure they could access care before the 12-week gestational limit, ideally in the community under ten weeks. They advised women when contacting a provider to explain they were calling after speaking with My Options to alert reception staff that they were seeking an abortion consultation. This minimised people using the terms ‘pregnancy’, ‘termination’ or ‘abortion’, which many found difficult, and alleviated anxiety regarding the potential response of a receptionist to a request for abortion care at a practice where they were not an existing patient.

Some questioned why information on abortion care could only be provided by a specialist helpline, arguing instead that as abortion is now a legally provided service they would expect that all medical professionals … would know enough about it to at least be able to point [abortion seekers] in the right direction (Pippa). My Options being the sole holder of provider information were challenged on the basis that it impedes people autonomously accessing a list of providers and diminishes capacity to ‘self-direct’ their pathway through reproductive health services.

You can’t just, even if you are doing it self-directed, you can’t really start it yourself, you need to go through somebody to get some information to then go to the next step. The information you need isn’t kind of readily available to access by yourself. (Elaine)

The My Options 24-hour nurse helpline providing abortion-specific medical advice and support was welcomed for being more specialised than general healthcare helplines. Most contacting the nurse helpline did so for reassurance that the symptoms they were experiencing were normal. Fiadh was grateful to have the helpline to ring and to talk to someone when she rang the helpline concerned she had only light bleeding but no cramping or pain after taking the second medication. She was advised to take the supplementary round of the medication given to her by her GP and overall found the service gave me a bit of relief. Two weeks after her medical abortion, Jill called the nurse helpline about bleeding she was experiencing and was told, it should be fine it’s normal bleeding. She further recalled being advised to keep track of how many pads that [she went] through within an hour and if it’s over a certain amount then [she needed] to contact the hospital or go to the hospital.

Overall, My Options seems to be serving people well by being a responsive, accessible, caring and continuous element of the care pathway. However, there is criticism that the model of care positions My Options as the sole source of information on GP abortion providers, and it was criticised for being an unnecessary conduit and additional step in accessing legally mandated healthcare. Some actively avoided the service for this reason but often ultimately had to contact My Options when efforts to directly access the service themselves were unsuccessful. This was a source of frustration and delay and portrayed as undermining autonomy.

My Options 24-hour nurse helpline was assessed positively for being easily accessible, especially out of hours. The service was reassuring to people as self-managing abortion care felt onerous. Staff were assessed as understanding and knowledgeable, supporting people to determine if they needed to take a second round of the second medication, if symptoms they were experiencing indicated they should present to their doctor or hospital, or simply if symptoms they reported were normal/could be self-managed. This component of the service supported care autonomy.

Managing logistics

Irish abortion law requires people under 12 weeks’ gestation to attend two consultations separated by a legally mandated three-day wait period before they can access care. While the initial model of care anticipated these as face-to-face consultations an amendment to the model introduced in April 2020 in response to the Covid-19 pandemic allows one or both consultations to be conducted remotely, at the discretion of the care provider. Study data suggests that even during pandemic restrictions most GPs required face-to-face attendance at one consultation, while WHCs offered two remote appointments. Participants detailed the various logistical arrangements that had to be made to facilitate attendance at one or both appointments including travel, scheduling, timing of medication and childcare.

As noted above, only about 10% of GPs in Ireland have opted into the contract to provide abortion, and there is an uneven geographical spread of providers requiring people in some areas to travel long distances to access abortion care (Duffy et al., 2023). Travelling to appointments was a particular challenge for those who did not drive, had no access to public transport, and/or had to travel long distances. In some cases, lifts had to be relied upon, as was the case for Diane whose friend [drove me to two appointments over an hour away] because [I don’t] have a full licence. Further, the disjointed nature of abortion services could mean travel to multiple locations for example to seperate faciliites to attend a GP and have a scan; Naomi portrayed this as jumping all around the place.

Those with work or education commitments needed appointments to fit in with their schedules. Some avoided taking leave by booking appointments on days off or scheduling them outside of work hours, like Clíona who said I could have gone back on Thursday and got the first tablet, but I decided because of work, I’m off on a Friday [to return on Friday] so it worked out quite well. Some had to attend ultrasound appointments, making for three consultations before accessing care and another opportunity for abortion care pathways to conflict with work commitments. Self-employed Gráinne noted that the availability of an out-of-hours scanning appointment would be more suitable for people like her.

Work or educational commitments also figured in the timing of abortion pills. Katherine timed it to be taken during the weekend that I was off work. Although initially Elaine planned to work the day after the abortion, she later decided against it as it was just all a bit too much. Most people recalled taking time off work to recover, often facilitated with a sick note by their care provider. Barbara opted not to take time off work and worked the day she took the misoprostol explaining What I would say is its actually more of a personal thing really to me … like I wouldn’t be one to kind of complain, though this was not the norm.

Children needed to be cared for during the abortion process. Travelling to appointments meant some had to arrange childcare. This could be anxiety-inducing as a potential breach of privacy, with Gráinne worried that questions would be asked as to why her child was not going with her when she normally brings her everywhere. As a woman who practiced attachment parenting, Fiadh spoke of the pain for her to travel over an hour to a scan at a hospital as her child could not be separated from her, made even more difficult by the fact her child was prone to car sickness.

Participants also discussed the need to co-ordinate taking the medication with childcare. It was common for those who had children to take the misoprostol after the children went to bed. Some arranged for children to be cared for by other family members or friends. Helen’s friend offered I’ll come over and we’ll have dinner together and I’ll sit with the kids so you can go to your room. It was important to women that their children were cared for during this time. Brie spoke at length about how she perceived the day-to-day tasks of parenting conflict with the experience of home-based medical abortion, especially for women with no other source of support. Brie questioned, How does she have an abortion and be a mother at the same time?.

Doctors provided women with medical certificates for their workplace if it was necessary to enable them to have some recovery time after having taken the pills as Jill describes: So, she gave me a doctor’s note so I took, because I was scheduled to work the Saturday and Sunday, so I ended up taking the Saturday and Sunday off. And I was already off work on Friday, so I took it in the morning and just had the weekend off. However, some avoided medical certificates out of concern that it might breach their privacy, as was the case for Katherine who didn’t want any questions, wanting instead to keep it as hush as possible.

Taking the first medication

The model of care anticipates people taking the first round of medication, mifepristone, at the second appointment with their doctor. They then return to the place they have planned to go through an abortion and 24 hours later take the second medication. Medication abortion was depicted in the data as protracted with 24-hour lapse between taking the two rounds of medication and an expected but indeterminate period and level of discomfort and bleeding.

Women described doctors giving a lot of attention to helping them identify the optimum time for them to take the abortion medication, having regard to their wider commitments and schedules. Providers spoke with women to determine the best time for them to take the second pill within the context of various other commitments like work or childcare. Aoife described how With the second pill they [GP] talked me through what I would do during the day, so I took it when my kids went to bed because my, after I had spoken to them I kind of reckoned I would rather have a rough night, you know that way rather than have to deal with it in the day when they’re up. I would rather have no sleep and be in some sort of, able to get out of bed the next day rather than during the day feeling dreadful, you know.

Symptoms people described after taking the first medication varied, though many remarked they felt nothing or were fine. Zoe said, I came home like and like I just stayed in bed, and then I was fine that night. After Hazel took the first medication, she was able to drive herself home noting it … didn’t affect me, no side effects, no symptoms. A few described experiencing some symptoms after taking the first medication. Diane noted a slight pain in my stomach about a half an hour afterwards … it was like shallow cramping, describing she was tired and […] just wanted to have a sleep to be honest. Orla felt a bit dizzy but nothing major (Orla).

Others had more debilitating symptoms. Fiona who had gone back to work after taking her first medication remembers I felt really bad from the mifepristone, that first pill and I was really weak, sick and had bleeding. This demonstrates potential impacts for women who do not find taking time off work straightforward. Similarly, Ruth noticed bleeding after the first medication. Others did not experience any physical symptoms as such, but expressed a sense that the pregnancy was in the process of ending feeling that’s what’s happened now, that’s done (Clíona), or had ended as Joy described: Yeah I knew on the Thursday night after I took the first pill that I was no longer pregnant.

There were accounts of taking both doses at home where the woman discussed her preferred schedule of care with her doctor and they determined this was best. For example, one woman who wanted to take the second medication on Saturday evening after her children went to bed took her first dose home at home so she could time taking the second round according to her preferred schedule.

Creating an abortion care setting at home

The Irish model of care does not make a facility available for a person undergoing medical abortion but rather anticipates the abortion will take place outside of a clinical facility – ‘at home’. Women spoke about the consideration they gave to ensuring that the environment they would be in during their abortion would be as comfortable as possible. Many engaged very purposively preparing their space to fit with what they expected to need during the process. Aine organised herself early in the day so that by the time she took her second medication, she could have some cosy down time (Áine). Discussing the steps she took to prepare for her medical abortion, Ruth emphasised the importance of a clean and comfortable environment, describing how she cleaned her house before taking the second medication to not have to worry and prepared the second bedroom in case she needed some personal space.

Some questioned how the model of care could be managed by a person without access to their own bed and bathroom, with Fiona expressing that there should a place offered for people without a suitable and secure ‘home’ environment where they could self-manage the abortion. Those living in shared housing or with their parents, spoke of the arrangements they made to ensure that they would have a suitable environment for the medical abortion. One person who lived in a house share had a hotel booked anyway […]in the city centre that coincided with seeking an abortion. She scheduled the abortion for that time and went through the medical abortion in the hotel. Others went to the house of a trusted friend or partner and went through the the abortion there.

Where an alternative place was not possible to arrange, women who shared their house with others who they did not want to know about their abortion had to carefully manage the process to maintain their privacy with considerable stress involved. Sarah managed her medical abortion in her parents’ house while not wanting her parents to know. She achieved this by taking the second pill early in the morning after her parents left for work and remaining home from school without their knowledge, then pretending to go to bed in the evening when they returned home. She noted that while this was manageable, it would have been a lot harder if [my parents] were like around and [I] would have had to like hide the whole day.

Diane spoke of having to take the second pill while her abusive ex-partner was in her house after he unexpectedly came over to visit their children. She did not want him to know she was pregnant but wanted to adhere to the advised timing of when to take the second pill, mindful of the guidance that she needed to hold them in her cheek for some time. She explained it was really like awkward because you have to hold them in your mouth for like a half an hour so I was in the shower and just trying to avoid him doing it. When the medication started to take effect she remembered "he was just like Jesus Christ you’re dying and I was like “oh yeah I’m grand, [my period has] just gone really bad". This highlights the potential risks a woman in a domestic violence or coercive situation might encounter managing a medical abortion with an abusive partner present. As the medical abortion managed at home can leave people physically vulnerable due to the blood loss and length of time to complete the process, being in a situation where they are concealing it from others they fear knowing they are having an abortion is far from ideal. Diane’s account raises concerns about managing the medical abortion in a space that may not be safe.

Self-caring for the aborting body

Women described preparations made to care for their bodies during the medical abortion designed to enable them to focus solely on the abortion in progress. Preparations included arranging to have pain relief, hot water bottle and sanitary towels. Katherine purposively had a meal before taking her second medication, aware that she might not want to while the abortion process was ongoing. Most people took time off work where this was possible anticipating that they would need to be completely unencumbered by other demands during the abortion process. Ursula took four days off from work I don’t know how exactly it happen, what will happen. Grainne reflected: it would want to be at a time where you’re able to not have to do anything, not have to walk, not have to be under pressure to be anywhere. Women noted that self-care in this process is essential. Terms like self-care, minding oneself, and taking it easy were used to describe ways of being gentle on the body during this time and careful planning was understood as part of minding the aborting body.

Informal supports during medical abortion

The data showed that most women who had a medical abortion took steps to ensure they had some informal support in place while they were taking the second medication themselves at home. Where women were in a relationship this was often provided by their partner. Pills were timed so that their effects would coincide when partners were home as well, while in some cases, partners took the day off. Serena remembered we both just spent that day kind of in bed watching Netflix, just talking or whatever. Laoise told her husband that he should go to work the day she took the misoprostol explaining that she was quite self-sufficient and quite independent by nature. However, when her bleeding became quite heavy, she called him to come home. Those who did not live with their partner spoke about arranging to be together during the abortion like Áine who said: my partner lives in [another city] so he made arrangements to come and be with me … .

Those not in a (close) relationship arranged support from other people in their lives. After being told that it’s very important to have someone around by the WHC she attended, Orla arranged for her friend to be with her in the hotel she was staying at as she was undergoing the process. Sarah who was having her abortion in her family home without her parents’ knowledge approached a friend for support before taking the first medication. She arranged for her friend to be available by phone throughout that day so she could come over if Sarah needed her she was like all supportive and she said if something happens, she can always come to my house, all I have to do is call her. Recalling the importance of knowing that her friend was on standby and would come over if needed was reassuring to her.

Taking the second medication and the onset of abortion

Women typically took the misoprostol in their own home, but we saw above how some went to a friend/partner’s house or a hotel where their living situation meant they were unprepared to take the medication at home. In the Irish model of care, Misoprostol is administered as the second medication. This is taken held in the cheek until dissolved (buccal) 24–48 hours after the first medication. Information people received from their doctor advised that the misoprostol will make the womb contract, causing cramping and bleeding with heavy bleeding usually starting 2 hours after taking the medication, though it may occur sooner or later. People were advised that possible side effects might include dizziness, nausea or vomiting, headache, diarrhoea, temporary flushes or sweats.

During interviews, women often re-enacted placing the pills inside their cheeks demonstrating strong attention to detail in following doctor’s advice. Victoria took the second medication and was satisfied the bleeding did start within the timeframe that they specified. Ursula noted feeling like something uncomfortable and then that my period start[ed] …  about two and a half hours after taking the misoprostol. Clíona timed it to be taken exactly 24 hours after the mifepristone was administered and remembered that when it all started to happen I just spent the day in bed, hot water bottle. And just kind of kept myself as comfortable as I could. Women’s accounts illustrate their great care when self-administering the misoprostol and that despite following instructions, several feared that they might inadvertently do it incorrectly when the pills did not fully dissolve within the expected amount of time. Fiona described having a panic attack while Pippa remembered watching the clock like a demon when the pills did not appear to be dissolving. When Brie’s medication only partially dissolved, she swallow[ed] the bit that’s left over and then […] got sick. When she later experienced a high temperature she began to panic describing My body just literally went … it just didn’t know what was going on at all like, the presence and support of her mother who is a qualified nurse were crucial for her.

Some described more pronounced symptoms. After taking the second medication, Joy described she was floored, reflecting that she’d had miscarriages as well so it was very similar […] it was pretty severe. Likewise, Hazel experienced very heavy cramping and very heavy bleeding, temperature however, having been warned about all that by her care provider meant she understood this was normal. Una explained that after she dissolved the tablets in her cheeks that started contracting the womb … after I swallowed the tablets 15 minutes it all started and, oh my god, its painful process and loads of, loads of awful, yeah scary actually to look at, you know but that’s what’s happening and all that, it’s very graphic type of thing. Like they said it’s the heaviest period ever. Una’s account demonstrates people’s attention to what was going on for their bodies. Zoe described how after taking the second medication she couldn’t even lie in bed, like I was sitting in the toilet, I was getting sick into a bag, like it was just awful … . This confined her to the bathroom for approximately four hours.

In contrast, several others noted that nothing happened after taking misopristol. Lack of cramping and loss of blood were interpreted as indications that the medication was not working, such as for Ruth who said I didn’t feel so much pain, I didn’t have so much blood. Similarly, Fiadh describes I started to get really worried, thinking this hasn’t worked. And then of course the phone comes out and I start googling what if it doesn’t work and I know I shouldn’t have but I was just, you know I was getting really worried at that point. Fiadh rang My Options nurse helpline and was advised to take an extra dose of the medication which brought bleeding a bit more but still no pain or cramping. This lack of symptoms was described as stressful and worrying. Laura took another dose 4 hours after the first medication as nothing had happened following advice her doctor gave her when dispensing the medication. When this dose took effect, Laura remembered: after 15 minutes shit happened.

Clíona described the abortion process as a physically draining day while Barbara outlined experiencing definitely discomfort and soreness and explained how her body felt:

I really was not in a good way but. … I wouldn’t say I was in great agony, I would say that I just felt like I needed to go home and crawl into the bed kind of, just not feeling great. But that was only for a few days.

Reading bodily signs that the abortion was complete

Women talked specifically about bodily signs that the abortion had completed from either sensations they felt or material their body passed during the process. The data demonstrated women as fully present and engaged with the medical abortion process, closely attending to embodied symptoms, bleeding and materials expelling from the body. Several explained knowing they had successfully completed the process through visual confirmation, like Jill who said yes, I would say [it had passed] because it was quite a bit. Helen explained that she was getting pains and then as she stood up she felt the pregnancy tissue pass abruptly.

Other women described feeling pregnancy tissue passing out of their bodies. Brie knew she had expelled it because she could feel something enormous. Elaine was able to identify the point in time explaining I passed a very large sort of clot and I was like right that’s it now. And then it started to ease off then after that giving her certainty that the pregnancy had been expelled. For Joy, feeling the materials pass reassured her that everything had worked. Similarly, when Brenda passed several clots at once she felt certain that the abortion was successful, thinking this is it, this is, it’s all coming out of me now. Cliona described I went and sat on the toilet and that was kind of, oh that’s happened now. Diane remembered the feeling of the body during childbirth and likened this part of the abortion process to passing the placenta in labour.

Some talked about not looking at materials and tissue they had passed from their body during the abortion process. Hazel said, No I didn’t monitor it myself, [my GP] said you know that its substantial while Ophelia remarked But no I couldn’t, I wasn’t going to inspect anything. Similarly, Gráinne wasn’t watching out for it but having experienced a previous miscarriage and knowing what that process was like, she explained: I wasn’t going to see anything, I knew, you know I knew that already. I’d imagine if I hadn’t been through it before I would have definitely been more watching out for.

Testing to confirm abortion

Participants are provided with a low-sensitivity pregnancy test by their providing doctor to self-administer two weeks after the medical abortion, to determine if the termination has been completed. Some participants reported a positive pregnancy test result at two weeks post-abortion, or in one case a scan detecting a failed abortion and they contacted their providers to query this. They were all asked to return to their provider for further tests ‘it was the faintest little line and I rang and I said to them listen on the box it says X, Y and Z and they were like oh no to be sure to be sure come in’ Naomi.

People reported very timely responses when seeking appointments to discuss a positive pregnancy test. Pathways differed once the provider had confirmed a positive pregnancy test. Most had the pregnancy test repeated at least once under the care of their provider and if still positive, were referred to the hospital. Others were referred for a scan to a maternity hospital which their providing doctor arranged, Brenda described receiving a call from her providing GP about 40 minutes after leaving the clinic to tell her to go down to [the scanning clinic] now and they’ll see you straight away. Women managing positive pregnancy tests referred back to their bodily experiences of the abortion process to make sense of this such as Renee who said it gave me some kind of comfort that I knew that I passed it. That I knew that it worked.

In a few cases where women had positive pregnancy tests following the abortion, their provider monitored their hormone levels rather than referring them to the hospital for scanning. Therese, returned to her providing GP and noted from Friday to Wednesday that her hormone levels indicating pregnancy were still like dropping a little bit but still high. One week after her last pregnancy test, she tested positive again and got another set of pills from the GP. These pills did not cause Therese to bleed. The next day, she was advised by an on-call doctor who was covering for her providing GP that she should go to a maternity hospital. Reflecting on her conversation with the on-call doctor, Therese said that it sounded like [the on-call doctor] would have recommended [returning to hospital] earlier, which made Therese question her providing GP’s expertise: I don’t know if I went to a different doctor would they have told me to like go to the maternity hospital like much sooner. Approximately four weeks had passed between Therese’s first round of pills and her being referred to a maternity hospital.

Similarly, Naomi was asked to return to the WHC she attended for repeat testing over several days, which was followed by a referral for a scan. As she got closer to the 12-week cut-off monitoring hormone levels was abandoned and she was referrned to hospital. Naomi describes they said to me ‘listen your bloods aren’t coming down, can you come in’ and it was great because they were like ‘oh we’re open till like whatever time this evening so just pop in’ and things like that, ‘you don’t need to make an appointment, just pop in and we’ll work around you’. And it was great like. And I did that for a couple of nights, Jesus I don’t know how many, I must have gone down about four times, three or four times. And then it was like ‘no you’re going to have to, if it doesn’t go down this time, you’re going to have to go in [to hospital]’ Naomi.

Closing out abortion process

Attendance at a third appointment in the absence of complications as provided for in the model of care (though not legally mandated) was infrequent. A small number of women reported returning to their provider for a face-to-face consult while a few others reported attending a follow-up appointment with their own GP. It was more the case for providing Doctors to check in with people by phone to inquire if all was well and if they had administered the pregnancy test and had a negative result as the care pathway sets out.

Those who attended GPs sometimes had this communication by text message but phone calls were more common across both provider types. Fiona had been asked to text the result to her provider, I text her that it is negative, her doctor responded, ok thank you very much and that completed their engagement. For many the telephone format of the post-abortion check-in by their provider was satisfactory, with many such as Clíona saying, I didn’t need to go back in. In a similar vein, Hazel explained that she would have travelled to a third appointment if necessary but the telephone format for the follow-up was better for her as it avoided having to travel: a phone call was even better but if I had to go, I would have, yeah no problem (Hazel).

There was a general consensus that such communication was an acceptable means of closing out the process of abortion. Receiving the follow-up communication felt supportive and was considered potentially very important for those without other supports: 

And it felt like they cared, you know the way that they called me after two weeks, they asked me if I needed to see someone to talk about it and I was like no, no, I’m good. (Laura)

Discussion

Since implementing legal abortion services in Ireland in 2019, the vast majority of abortions provided in the Irish healthcare setting are under s.12 of the Act providing for abortion without any qualifying restrictions up to twelve weeks gestation. The model of care implemented for abortion under twelve weeks gestation centres on providing MA in primary care through General Practitioners and a small network of Women’s Health Clinics, what Mishtal et al. (2022) characterise as an Irish community model of medical abortion.

Analysis of qualitative interviews of people’s experiences of abortion care in the Irish healthcare system demonstrates how this community model of medical abortion involves a hybrid of self-managing abortion outside of clinical settings in the context of the legally regulated provision of medication, information and support from a network of formal and informal community care providers. Pizzarossa and Nandagiri (2021) conceptualise self-management of abortion:

as consisting of a range of individual activities–a multiplicity of behaviours and navigations that surround abortion self-use (e.g. self-sourcing, potentially necessitating (unpaid) leave from work, arranging childcare and management of symptoms or complications, confirmation of abortion), and the collective dimension that enables safe self-use through a constellation of actors and interlocutors (e.g. friends, partners, family members, community health intermediaries, pharmacists, activists, non-profit organisations, hotline operators, accompaniment networks, doulas) who undertake a number of activities (e.g. provision of accurate information, sourcing of pills, accompaniment through the process, child-care provision) to support peoples’ SMA trajectories. (p. 24)

The Irish community model of medical abortion does not entail self-sourcing of medication because it is provided through community General Practitioners and doctors in Women’s Health Clinics. The health service implemented a helpline as a centralised point of entry for accessing care entitled My Options. Women in our study found the telephone format more acceptable given the effect of the stigma attaching to abortion making them hesitant and anxious about approaching services. The caring and helpful response from My Options staff, reassurance that the GPs they are approaching are abortion providers and getting a prompt to use when calling to make an abortion-related appointment at an unfamiliar GP’s practice were all considered supportive of abortion care access. While the principal perspective on My Options was that it facilitated accessibility, some queried why details of providing GPs are not openly available allowing them to avoid this conduit and self-direct their care more or why all GPs would not be able to refer women to a GP providing abortion care. The latter view reflected participants with a greater sense of autonomy who felt they could withstand stigma or judgement regarding abortion whereas those wishing to avoid the effects of stigma valued My Options more.

Access to medication abortion is regulated by legislation that requires a person seeking abortion care to attend two consultations with their doctor, separated by 3 days, before they can access care. This requirement of a waiting period is exceptional for abortion. It evokes the concept of abortion exceptionalism proposed by Joffe and Schroeder (2021) as where abortion is regulated both differently and more stringently than other medical procedures comparable in complexity and safety (2021, p. 5). Millar (2022) employs the concept as referring to various discourses and practices that differentiate abortion from routine medical care specifying ‘over-regulation’ as a distinctive example of abortion exceptionalism. Discursively the wait period is framed as ‘time to reflect’,² inherently querying women’s decision-making in seeking care.

The model of care initially anticipated both consultations would be face-to-face but adaptations during Covid demonstrated that a fully remote or hybrid (one remote and one face-to-face) model of care is possible. In practice however GPs tended to retain at least one face-to-face consultation and, in many cases, have reverted to both being face-to-face. The data highlighted logistical challenges involved in attending in-person appointments particularly when there is no providing GP local to a person seeking care, combined with getting time off work, organising cover for caring responsibilities and organising transport. The data in this study would support the retention of hybrid or fully remote consultations for abortion care as a measure to somewhat mitigate the effects of the legally mandated three-day wait while it remains in place.

The Irish model of community medical abortion assumes people will self-care during the medical abortion process at home by taking the first medication in the doctor’s surgery, leaving there immediately to go to a comfortable, safe and appropriate ‘home’ environment and self-administer the second abortion medication twenty-four hours later. In the data, women depicted preparations they made to provide for this period of self-care. Those who could return home to a suitable environment where they lived with others - partners, parents or housemates who were compassionate and supportive, described preparing their environment to be comfortable and restful and having the facilities they needed there to care for themselves.

However, we also saw the strain people who were not in such situations were under to self-care during their abortion and self-administer the medication. A young woman living with her parents who she did not wish to know about her pregnancy had to covertly self-manage her care in her room with support available in the form of a friend contactable by phone who could come to assist her if needed. A woman co-parenting with a violent ex-partner had to covertly administer the second medication while he was in the house and explain away the symptoms of the abortion. This highlights how this model does not accommodate people out of home or co-resident with others who would not be supportive of them during abortion and suggests the model of care would be more acceptable and appropriate to all women’s needs if a community facility was offered where medication abortion could be (self-)administered if needed.

Women described being attuned to their aborting body during the timeframe of the medication taking effect, attending carefully to buccal administration of the second medication, having varying and indeterminate levels of pain and bleeding, noticing when significant amounts of tissue passed from the body indicating the abortion in process. Those who felt they had observed the pregnancy terminating felt reassured that it had been completed. For some women, the symptoms were acute and debilitating and caused them worry and distress with some calling the Nurse helpline component of My Options for advice which was a reassuring resource.

There were a few people interviewed who had a positive pregnancy test or a scan indicating ongoing pregnancy following the medical abortion. While monitoring bloods for declining hormone levels was sufficient management for some, others would have preferred earlier referral to a hospital for management of a queried failed medical abortion.

Conclusion

Analysis of qualitative interviews of people’s experiences of abortion care in the Irish healthcare system demonstrates that the Irish community model of medical abortion involves a hybrid of self-managing abortion outside of clinical settings in the context of the legally regulated provision of medication, information and support from a network of community care providers including helpline staff, counsellors and GPs. The findings here show this innovative model of care does achieve many of the aspects of self-managed abortion characteristic of self-managed abortion and people-centred care comprising dignity, autonomy and self-determination, confidentiality, communication, social support, supportive care, compassion, solidarity and trust. But these are limited by two features – legal regulation and absence of availability of community care facilities options while self-managing the abortion process.

The legally mandated three-day wait cuts across autonomy and self-determination associated with self-managed abortion. The over-regulation of medication abortion to purposely impede and delay access to medication through an imposed period of reflection has the effect of diverging the Irish community model of medical abortion from self-management as self-sourcing does not involve being subjected to such an imposed reflection time.

The absence of a community healthcare facility where the medication abortion can take place expects that all abortion seekers have a safe and appropriate place, ‘home’, where they can self-care for their aborting body during a medical abortion. This disregards the situation of people who do not have safe, independent homes including people living in situations of domestic violence, those out of home and those co-resident with families or others they do not wish to be accompaniments to their abortion. WHO guidance states that it should be the individual (i.e. the ‘self’) who drives the process of deciding which aspects of abortion care will be self-managed and which aspects will be supported or provided by trained health workers or in a healthcare facility. This is not achieved by the Irish model with no community facility in place while access to the hospital-based services is heavily circumscribed by a very over-stretched health system. Until these are realistic options for the abortion service, there is a risk women will be directed into the self-management model of abortion care due to a non-functioning health system rather than choice.

The Irish model of community medical abortion is innovative and potentially transformative for abortion access. However aspects of legal regulation need reform and the health system needs to expand to encompass more GP providers, daycare facilities and greater access to hospital care to achieve the level of people-centredness abortion self-management has the potential to realise.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This work was supported by the HSE Sexual Health and Crisis Pregnancy Programme [grant number 16123].

Notes on contributors

Catherine Conlon

Catherine Conlon is an Associate Professor of Social Policy in the School of Social Work and Social Policy, Trinity College Dublin. She is a co-PI on the HEA North South Research Project funded Reproductive Citizenship (ReproCit) Project and was PI on the HSE’s Unplanned Pregnancy and Abortion Care Study (UnPAC), the service user research strand of the 2022 Review of the Health (Regulation of Termination) Act 2018.

K. Antosik-Parsons

Kate Antosik-Parsons is a Postdoctoral Research Fellow in the School of Social Work and Social Policy, Trinity College Dublin, on the HEA North–South Research Project funded Reproductive Citizenship (ReproCit) Project. She was a co-author of the Unplanned Pregnancy and Abortion Care Study (UnPAC).

É. Butler

Éadaoin Butler is an Adjunct Assistant Professor in the School of Social Work and Social Policy, Trinity College Dublin. She was a co-author of the Unplanned Pregnancy and Abortion Care Study (UnPAC).

Notes

1 There is a slight underestimate here as it is known that some Contracts are issued to GPs in group practices where there is more than one providing doctor relating to that one contract. However, it does not considerably alter the coverage of providers.

2 See discussion at Oireachtas Joint Committee on Health Report of the Review of the Operation of the Health (Regulation of Termination of Pregnancy) Act 2018: Discussion 31st May 2023 Joint Committee on Health debate – Wednesday, 31 May 2023 (oireachtas.ie).