Knowledge and attitudes of Irish GPs towards abortion following its legalisation: a cross-sectional study

Summary

To the authors’ knowledge, this is the first such survey to have taken place in Ireland since the legalisation of abortion.¹⁷ The results indicated mixed views on the provision of abortion services by GPs in Ireland. Less than half of responders (n = 53, 41.7%) believed that abortion service should be part of general practice, with a further 17.3% (n = 22) indicating that they were unsure if the service should be provided in this context. While almost half of those surveyed indicated a willingness to prescribe abortion pills (n = 61, 48.0%), over a third would not do so (n = 47, 37.0%). The majority of responders were willing to share abortion information with their patients (n = 119, 93.7%) and many had already done so (n = 77, 60.6%); however, a majority also felt that necessary services, such as counselling, are not available for women with unwanted pregnancies (n = 89, 70.1%). Since the introduction of the abortion service in January 2019, the Irish Health Services Executive has set up counselling services for women with unwanted pregnancies both by telephone and online (but not face-to-face) via the My Options service.¹⁸

There is a considerable lack of experience and training among Irish GPs in this area. Over 40% (n = 52) of responders reported having very little or no experience in the area (Table 4), 82.7% (n = 105) reported that they had received no training, and only 3.1% (n = 4) reported that they had sufficient training to provide a service (Table 2). Between December 2018 and March 2019 the Irish College of General Practitioners (ICGP) has provided training to 208 GPs through four workshops, with a further two workshops planned in April and May 2019. These figures amount to less than 5% of the total GP population. At the time of writing, over 600 health professionals (including GPs, practice nurses, and midwives) have attended training with the Southern Taskgroup on Abortion and Reproductive Topics training meetings since 1 January 2019.¹⁹ Furthermore, the ICGP published I nterim C linical S upport G uidelines in January 2019.²⁰

At the time of writing (18 July 2019), 335 GPs have signed a contract to provide abortion services (O'Brien, personal communication, 2019); however, the overall number of GPs receiving training is problematic given the low levels of experience and training, and the desire for further education indicated by participants in this study.

The issue of the availability of an exemption for those with a CO, and the extent of that exemption, has been controversial in Ireland.²¹ The majority of responders believed that those who do not wish to be part of the process should be entitled to a CO, but should also be obliged to refer a woman to a participating doctor (n = 92, 72.4%).

Strengths and limitations

This study had many strengths. The fact that it was short and anonymous encouraged a fair response rate of 57%, which is high for a GP survey.²² All of the study responders were actively practising GPs. The location of the responders was nationally representative (supplementary Table S1) and responders came from three out of the four healthcare regions in Ireland.

The age and sex of responders were not nationally representative (supplementary tables 2 and 3). Responders were more likely to be younger and female than the national profile; however, it is likely that young female patients with unwanted pregnancies will tend to seek out young female doctors, therefore the sample may actually be more representative for the GPs seen by these young women than a traditionally representative sample, and so this is a strength rather than a limitation.

One limitation of the study was that the authors only surveyed GPs who were affiliated with GEMS and recent graduates of the University of Limerick Specialist Training Programme in General Practice. It is possible that GPs without such an affiliation might have responded differently. It is possible, though unlikely, that the same GP could have answered multiple questionnaires from different internet protocol (IP) addresses. Furthermore, it is also possible that GPs who were less comfortable with electronic media were less likely to answer the questionnaire; however, as over 94% of Irish GPs are able to work with computerised records,¹⁶ this is very unlikely.

Comparison with existing literature

Patient access to abortion information is considered essential, as all women need evidence-guided information in order to make a fully informed decision in the case of unwanted pregnancy.²³ Of the total responders, 60.6% (n = 77) answered that they had shared information about abortion with one of their patients in the previous 12 months, compared to 45% in a 6-month period in an earlier Irish survey,²⁴ indicating that women appear to be engaging with their GPs in recent years when considering accessing an abortion in another country.

Recently published research involving women who had either travelled abroad to access abortion in a clinic or had self-managed a medical abortion at home in Ireland using online telemedicine, suggested that irrespective of the pathway chosen, women experience a lack of pre- and post-abortion support in the Irish healthcare system.²⁵ Waiting times for these services may extend to several weeks though this may be aided by the recently introduced My Options service.¹⁸ Guidelines in other jurisdictions state that women should have access to objective information and counselling about their pregnancy options in the case of unwanted pregnancy.²⁶ While some studies show that women may experience mental health problems following abortion,^27–30 others have challenged this.^31,32 In any case, support techniques for a more informed choice are needed.³³

This survey pointed to a significant minority of GPs who were not willing to prescribe abortion pills and/or did not feel that this service should be provided as part of general practice. An earlier Irish study showed that 10% of responders were of the view that abortion can never be allowed and 25% took the view that it can only be allowed in limited circumstances.²⁴ The authors do not know if the reluctance on the part of responders to this study is ideological, due to a lack or training and/or expertise, or linked to the feeling that this service should not be provided in already overstretched GP practices, or for other reasons.

There are many barriers to the provision of first trimester abortion services, which include moral opposition, lack of training, busy physicians, staff harassment, and insufficient resources,³⁴ all of which may contribute to a reluctance to provide first trimester abortion services. The World Health Organization supports the provision of abortion services at primary care level;³⁵ however, evidence of support for a GP-led abortion service internationally is inconclusive. It has been argued that GPs are ideally placed to provide a community-led abortion service, particularly in rural and regional communities, a view supported by a qualitative study of 15 experts in abortion service provision conducted in Australia,³⁶ though a descriptive-interpretive qualitative study of 32 Australian GPs found that some saw abortion as beyond the scope of their practice.³⁷ Some GPs had religious or moral objections; others regarded abortion provision as complicated and difficult, and while some GPs expressed interest in abortion provision, they were concerned about stigma and the impact it may have on perceptions of their practice and the views of colleagues.³⁷ A qualitative study of 30 obstetricians/gynaecologists found that the stigma and ideological contention surrounding abortion serve as barriers to the integration of abortion into medical practice.³⁸ Alternatives to a GP-led service include primary care abortion clinics³⁹ and abortion services supplied by non-doctor, ’mid-level’ healthcare providers.⁴⁰

This research showed strong support for respecting CO in GP practices in Ireland. Chavkin et al argue that the ingredients that appear necessary for a functional health system that guarantees access to abortion while still permitting CO include clarity about who can object and ready access by mandating referral.⁴¹

Implications for research and practice

The immediate implications for practice are the need for education courses for GPs on the provision of abortion services. The provision of integrated training in reproductive health⁴² and the provision of an elective advanced training and leadership programme for senior residents in family medicine⁴³ have been shown to be effective.

Beyond the legal changes which have been implemented following the societal conversation on abortion in Ireland in recent times, there are many conversations on public policy on reproductive health which are currently being grappled with. The Citizens’ Assembly,⁷ the influential body comprising 99 citizens randomly selected to be broadly representative of the Irish electorate established to consider some of the most important issues facing Ireland’s future, including access to abortion, went beyond recommending legal changes to make some significant policy recommendations. Some of these recommendations have significant implications for general practice, including improved access to ’ family planning services, contraception, perinatal hospice care […] to counselling and support facilities for pregnant women both during pregnancy and, if necessary, following a termination of pregnancy, throughout the country’.⁷ The Joint Committee on the Eighth Amendment of the Constitution subsequently recommended that a scheme for the provision of free contraception be introduced, leading the Minister for Health to establish a Working Group on Access to Contraception in 2019 to consider the policy, regulatory, and legislative issues relating to better access to contraception.⁸ Should the government act to implement these policy recommendations, the landscape for GPs providing reproductive health care for women in Ireland will change dramatically.

The authors plan to repeat the study at the end of 12 months to reassess attitudes, knowledge, and (now) experience of GPs with providing the service. The authors also plan to assess centrally collected statistics and to study women’s experience of medical abortion in Ireland.