My name is Dr. Ciara McCarthy and I am a Cork GP and the Irish College of GPs and HSE GP clinical lead in women's health. I am joined by my colleagues Dr. Suzanne Kelly, deputy medical director, and Dr. Diarmuid Quinlan, medical director of the Irish College of GPs. On behalf of the Irish College of GPs, we thank the Cathaoirleach and the members of the committee for the opportunity to contribute to the joint health committee's consideration of the proposed amendment. The Irish College of GPs aims to support patients and GPs by encouraging and maintaining the highest standards of general practice, education and training. We are the professional body for general practice in Ireland, with a membership of 4,900 GPs. GPs in Ireland manage the vast majority of patient contacts across the health system, with GPs and practice nurses conducting in excess of 29 million consultations per annum. Abortion care is one facet of the comprehensive women's healthcare currently delivered in general practice, which includes the provision of contraception, antenatal and postnatal care, endometriosis care, menopause care and cervical screening.
Abortion care in general practice follows a three-visit model. There is an initial first consultation whereby a woman's decision is discussed, with referral for counselling and time for further reflection if required. Medical eligibility is assessed and sufficient information is given to the woman to enable her to make informed consent. Testing for sexually transmitted infections and the provision of information about contraceptive methods may also take place. A second consultation follows whereby the woman confirms she wishes to proceed with a medical abortion and informed consent is obtained. The abortion process is initiated, details around emergency contraceptive care are provided, and follow-up is arranged. Many forms of contraception may be initiated at this visit. Finally, a third visit takes place two weeks after the second, whereby the success and completion of the early medical abortion is confirmed and a woman's physical and psychological well-being is assessed.
The proposed amendment would remove the legally mandated three-day waiting period which currently exists, whereby a minimum of three days must elapse following a woman's initial consultation before she can commence a medical or surgical abortion. The content of our presentation will consider the practical, procedural and organisational issues that may arise if the amendment is passed, and their implications for patient care, and outline the published clinical academic evidence that supports the amendment.
Abortion care in the form of early medical abortion has been provided in Irish general practice since January 2019 and is underpinned by section 12 of the Health (Regulation of Termination of Pregnancy) Act 2018. That section of the Act provides for termination of pregnancy up to 12 weeks' gestation. There are currently 498 holders of termination-of-pregnancy services contracts in primary care, with the majority of these being GPs. The Irish College of GPs has developed a range of educational and clinical supports to assist GPs who provide abortion care in their practices. Guidance for GPs who do not provide abortion services has also been developed by the college to support members in meeting their ethical and legal obligations.
I will now consider the practical, procedural and organisational implications of the amendment. First and foremost, a woman's individual decision-making process must continue to be supported if the proposed amendment is passed. Women seeking abortion care present with varying levels of clinical need and at different stages in the decision-making process. It is imperative that the proposed amendment supports the importance of a reflection period for women who require it. The length of this reflection period should be responsive to a woman's individual needs and should be determined by the woman in consultation with her doctor, rather than being legally mandated. This allows for the delivery of personalised, holistic and comprehensive care, including the provision of post-abortion contraception, testing for sexually transmitted infections, and screening for gender-based violence where appropriate.
Second, it is well documented that many women face barriers in accessing healthcare, including abortion care. The mandatory three-day wait can disproportionately impact women already navigating obstacles to healthcare: poverty, disability, gender-based violence, homelessness and addiction, to name but a few. The proposed amendment would enable increased flexibility in scheduling appointments for women while ensuring that the care delivered is individualised but also underpinned by strong clinical judgment, informed consent and careful safeguarding.
Third, the current mandatory three-day waiting period can alter the clinical care pathway for some women. Hospital care is necessary if the gestational age exceeds nine weeks and six days by the time the mandatory waiting period has elapsed. Hospital-based care may result in additional visits for the woman, increased emotional distress or longer distances to travel in order to access care, and may increase the complexity of care co-ordination and delivery for the healthcare system. For a smaller group of women, the current mandatory waiting period may result in an inability to access abortion care in Ireland. Some women may present for care within the gestational limit of section 12 of the Act but will have exceeded 12 weeks' gestation by the end of the mandatory waiting period and are therefore not eligible to access abortion care in Ireland. The proposed amendment would better align clinical and legislative frameworks for these groups of women, which would allow personalised care to be delivered in primary care when deemed to be safe, appropriate and acceptable to the woman.
A body of national and international evidence considers the impact of mandatory waiting periods for those accessing abortion care. The World Health Organization's abortion care guideline, published in 2022, advises against the use of mandatory waiting periods in abortion care. The evidence demonstrates that mandatory waiting periods can delay or restrict access to abortion care, can increase emotional distress and can create logistical difficulties for both the woman and healthcare systems.
In Ireland, the unplanned pregnancy and abortion care, UnPAC study, published in 2022, provided a qualitative review of abortion care services in Ireland. Women who had used abortion services who were interviewed in the course of the study noted that the mandatory waiting period had little to no impact on their personal decision-making process.
The independent review of the operation of the Health (Regulation of Termination of Pregnancy) Act 2018, published in 2023, concluded that the statutory three-day waiting period results in delays in accessing care and increases the psychological and physical burden carried by women. The review recommended replacement of the mandatory waiting period with a discretionary reflection period.
The HSE model of care for termination of pregnancy services underpins the provision of high-quality, woman-centred care and is supported by clinical guidance from the Irish College of GPs and the HSE. The proposed amendment better aligns legislation with these clinical frameworks, supporting comprehensive clinical care while considering a woman's individual needs and preferences. Abortion care must continue to be woman-centred, incorporating time for reflection and decision-making where required while maintaining high standards of clinical assessment, informed consent, safeguarding and continuity of care, including the provision of post-abortion contraception where appropriate.
The Irish College of GPs will continue to support GP providers of early medical abortion through the provision of clinical guidance and regular educational updates. Any legislative change will be reflected in this clinical guidance, ensuring care is compliant with current legislation, evidence based and patient centred.
Gabhaim buíochas leis na comhaltaí go léir.
