Ireland voted in May of last year to allow doctors like me to look after women with complicated pregnancies and provide complete care, including terminations, in our hospitals.
Termination of pregnancy, within the provisions of the law, has now been legal for six months.
I campaigned for a Yes vote in last year’s referendum and repeal of the Eighth Amendment has led to a positive change in reproductive healthcare in maternity hospitals. But the reality is that we have not introduced a high quality or accessible service.
Why? Because there has been no leadership, little resourcing, limited education and a fundamental failure to recognise the complexities involved.
First, it is important to distinguish between community care and hospital care. Our GP colleagues have led by example. They have taken on new roles, educated themselves, advocated for their patients, spoken out against opposition and set up peer-to-peer training and support networks.
Unfortunately, the same has not happened in all maternity hospitals. Just ten out of 19 maternity hospitals or units are providing aspects of the service. Women in parts of the country still have no access to termination of pregnancy services.
This cannot be blamed on conscientious objection alone. Vital preparatory work was not done to facilitate the new services.
Hospitals are large, complex organisations with defined cultures. Education and training is needed to help change those cultures and introduce a new and potentially disruptive service.
In some hospitals, staff committed to providing care can feel isolated and undermined. Clinical cases can prove divisive among healthcare staff and specialists, which affects working relationships. Doctors like me are being judged by other staff for our views and practice. This is creating conflict in what is an already stressful environment. Some specialists will not agree to any role in the provision of this service, either for pregnant women or caring for babies with fatal foetal abnormalities born alive after a late termination.
Clinicians’ interpretations of the law vary, and are undoubtedly affected by the fact that terminations are still criminalised in certain circumstances.
Barriers to practice are being created at local level under the guise of hospital policies. These, too, demonstrate a lack of trust among colleagues. There are also many so-called ‘convenient objectors’, especially where hospital management does not clearly support providers. Some hospitals have been slow to provide teaching and to facilitate discussions or even name providers of termination services for GP colleagues.
Some healthcare professionals who want to deliver this service feel out of their depth. Many have never worked outside Ireland to see this type of service in practice, but the educational opportunities available to them are limited. Termination of pregnancy represents a huge change in clinical practice, which they see as being forced upon them in a rush.
At a basic level, it has meant a greater workload with no increase in staffing, in overstretched hospitals and on busy wards. This can mean women experiencing all types of pregnancy complications being treated side by side with those undergoing terminations.
Hospital managers were expected to introduce the service in January, with very little preparation. Some were overwhelmed and I believe many have struggled with a lack of knowledge and resources.
Midwife co-ordinators for terminations were appointed in hospitals and ultrasound scans are being provided. Yet this has happened in complete isolation and is far from an integrated, clinically led service.
It is disappointing that the provision of ultrasound for the community was sourced from the private sector, rather than resourcing existing maternity hospitals’ early pregnancy units.
We have been promised that more money for new staff and for upgraded facilities will materialise. We have heard such promises before. The continued absence, some six months in, of a structured and well-resourced implementation programme is a huge concern.
Many of us were not included in rushed resource proposals that were delivered to the Department of Health in December. Most of those plans also covered early pregnancy care, with no focus on the speciality of maternal-foetal medicine.
This is despite many representations from our national working group, where concerns were expressed about access, resources, training and the ability to deliver a high-quality service.
We still do not have a national policy on prenatal screening, nor any access without cost. We do not have universal access to dating scans or anomaly scans, nor national ultrasound guidelines on best practice. Our hospital referral pathways remain largely informal, and clinical practices and decision-making are likely to vary across units.
Our professional bodies provided some training sessions and guidance by January, but guidelines do not implement themselves. Nor is it the job of the Royal College of Physicians or the Institute of Obstetricians and Gynaecologists (IOG) to resolve issues with service delivery.
It remains unclear who exactly is responsible for implementation of termination services in maternity hospitals, and who is responsible when problems arise. There also appear to be no plans to widen provision of services.
There has been nobody available to answer my queries in the past few months, nor to help me and my colleagues establish a service, nor to protect or defend us as we speak up for our patients and work with a very small number of colleagues nationally to deliver this service.
Equally worrying is the long-term impact of this on hardworking maternity hospital staff. Professional practice and relationships between colleagues have been undermined.
Doctors are concerned that they will be blamed for adverse outcomes, inevitable service failings and inequities in access and variations in care. For many of us, the lack of support, resources, structure and leadership in our health services is hard to forgive. It is unfair to pregnant women and their families. They have a right to expect excellence and professionalism in care around termination of pregnancy in all scenarios at all our hospitals.
It is also unfair to healthcare professionals who are the relentless target of patient expectation, negative publicity, civil society’s mandates, increasing service demands, healthcare complexity and, as ever, political expediency.
Dr Keelin O’Donoghue is a consultant obstetrician and maternal-foetal medicine specialist at Cork University Maternity Hospital. She is national implementation lead for the HSE national standards for bereavement care following pregnancy loss and perinatal death. She wrote national guidance on termination of pregnancy for foetal anomaly, as well as perinatal palliative care. This piece represents her personal views and not those of her employers.