Dr Kevin McCarroll
One year has just passed since the referendum paved the way for the introduction of abortion services in Ireland in January. The Regulation of Termination of Pregnancy Act 2018 permits abortion during the first 12 weeks of pregnancy without any specifed reason and in cases where there is a serious risk to the health or life of the mother. In addition, abortion is also permitted at any stage of pregnancy where there is a fatal foetal abnormality.
Abortion cannot be considered in any fundamental sense a healthcare issue given that nearly 97% of cases occur in healthy woman who have healthy babies. Indeed, one of the core ethical principles in medicine has been summed up in the maxim ‘primum non nocere’ – ‘first do no harm’ and the ancient Hippocratic oath also forbade abortion.
Whether one agrees with abortion or not, the leglislation poses serious ethical questions around issues such as the right to conscientious objection. Under the current law, a doctor who does not provide abortion on request for their patient and is ethically opposed to it, must refer to another physician who does, and are thereby legally mandated to materially co-operate in a way which is fundamentally against their conscience.
Concerns have also arisen regarding increased pressures that may be placed on the healthcare system and on the extent of advance planning prior to services being rolled out. For example, it envisaged that about 20% of all abortions will take place between 9-12 weeks gestation and in such cases the procedure will be carried out in hospital. In addition, establishing accurately gestational age requires ultrasound imaging in some cases and indeed, there has already been an increase in the demand for prenatal scans for some healthcare providers.
At present, 10 out of 19 maternity units in the country provide abortions as do just over 10% of GP’s (300+) though there are some counties where no doctors have agreed to provide the service. The HSE has budgeted €12 million this year for the service with GPs getting a reimbursement of about €450 per case (a fee which is actually more than that for GP care for women during pregnancy).
So how many abortions are occurring? It has been estimated that there have been over 800 abortions carried out every month since January though official figures are not available and will be not be compiled until the end of the year.
However, some doctors have estimated that up to 10,000 abortions may take place annually. Such a number would represent a substantial increase when compared to the total number of Irish women accessing abortions in the UK and Netherlands in previous years as well the estimated numbers who obtained abortion pills online.
Looking to the UK for some perspective on figures, shows that in 2016 of all Irish women accessing services (3265), 21% had already had a previous abortion and overall 85% occured within 12 weeks.
In the same year, 4.3% of all Irish women (141) had abortions due to a diagnosis of a physical or mental health condition of the foetus. Of these, the majority had chromosomal abnormalites including Down Syndrome (30.5%), Edwards syndrome (14.2%) and Patau syndrome (2.8%) while neurological conditions such as Spina bifida (4.2%), anencephaly (9.2%) and others accounted for a smaller number.
The recent story of an abortion of a healthy baby believed to have Edwards syndrome (on the basis of two initial tests) which later proved to a be misdiagnosis highlights some concerns with testing. At 10 weeks gestation, noninvasive prenatal genetic testing with a simple maternal blood test (to identify foetal DNA) can be used to screen for Edwards, Patau and Down syndrome and may indicate a higher chance of the disorder. Studies report a detection rate of up to 97.4% for Patau syndrome and 99% for Down syndrome but with varied false positive rates.
More definitive tests are those that examine foetal cells from the placenta via chorionic villus sampling (usually between 11-14 weeks and is 99%+ accurate) or directly via amniocentesis (15-20 weeks) which is more conclusive. However, both tests carry a risk of miscarriage of between 0.5-1.0%.
While invasive testing can rarely give false positives it ultimately can create a ‘life or death situation’ for a potentially healthy baby. Indeed, just this month there was a report of another pregnant mother in Ireland whose baby was diagnosed with Edwards syndrome after placental testing but opted to have amniocentesis which confirmed no abnormality.
Time will tell as to the full extent of the effect of the new leglisation on the number of women seeking abortion. No doubt too, there will be future complex cases that will arise that will pose serious ethical questions.
Dr Kevin McCarroll is a Consultant Physician in Geriatric Medicine, St James’s Hospital, Dublin.