Abortion has been available in Ireland since January 2019. Telemedicine abortion has been an option for almost half of that time. It expands patient choices and supports reproductive autonomy. Yet, women and pregnant people might be summarily deprived of this critical innovation.
Early in the Covid-19 pandemic, the HSE revised the model of care for abortion services to allow doctors to provide care via phone or video consultations. “Telemedicine abortion”, both as a primary mode of care delivery and in combination with in-person care, has enabled community providers of early abortion care to maintain an essential health service, while minimising the risk of Covid-19 exposure for both patients and staff.
Telemedicine abortion is endorsed by global reproductive health standard-setting bodies such as the International Federation of Gynecology and Obstetrics and the UK Royal College of Obstetricians and Gynaecologists. It is supported by strong international evidence: a 2019 systematic review found it has similar outcomes to in-person care, and a recent major study of over 50,000 women in England concluded that it is effective, safe and improves access to care.
Despite this, telemedicine abortion could be dropped from the care pathway. In a letter on March 22 to the Oireachtas Health Committee, the Department of Health stated that telemedicine abortion will “lapse” when the pandemic is declared over. This is not only at odds with the evidence, it contradicts previous assurances to the Oireachtas by the Minister for Health that a review of remote consultation for abortion care would be carried out.
To withdraw this innovative mode of service delivery without assessing its benefits would be short-sighted and contrary to international evidence. There is no health rationale for depriving women of this option.
As a provider of early abortion care, the IFPA knows that it works well and enhances patient choices, enabling people to access care in a manner consistent with their own needs and preferences. The permanent integration of telemedicine into abortion care could significantly improve access for a range of individuals.
To simply discard telemedicine would exacerbate the access barriers they face.
Evidence from the United States and Australia indicates that telemedicine care is a valuable support for those living in remote areas. There are no national data on the distribution of abortion providers in Ireland, although it is known that only half of the country’s maternity units (10/19) provide the full range of abortion services, and there is one county with no community-level provider.
In introducing remote consultation, the government and the HSE recognised abortion as essential, time-sensitive healthcare and prioritised people’s right to access the service. This was an evidence-based approach that protected public health and supported reproductive autonomy.
These are the considerations that must underpin the forthcoming review of the 2018 abortion law.
Due to commence this year, the review is intended to evaluate the implementation of legislation introduced when abortion provision was limited to cases of risk to life.
We can now assess abortion provision in light of women’s and providers’ experiences in practice. An assessment of positive, patient-centred developments such as telemedicine should form part of this process. But there are many other issues to be addressed.
Abortion remains a criminal offence. Doctors providing abortion in cases of fatal fetal anomaly have highlighted the challenges of working under ‘ambiguous’ and ‘restrictive’ legislation with the risk of criminal sanctions. The criteria for accessing abortion for health reasons are extremely narrow, with only 21 women accessing care under this ground in 2019.
The IFPA knows from our services of the stress and anxiety caused by the mandatory three-day waiting period. Our patients include women who have had to travel abroad for abortion, even during the pandemic, because their pregnancy fell outside the gestational limit and the criteria for eligibility after 12 weeks of pregnancy.
The review will provide a critical opportunity to address the flaws in the legal framework. It will allow policy-makers to learn from those who have sought and provided abortion care since January 2019 and to draw on Irish and international evidence concerning best practice and human rights standards.
The evidence is clear. In order to ensure access to abortion in law and practice for all who need it, telemedicine must be maintained. Its retention beyond the pandemic, within a blended approach to abortion provision, would expand patient choices and support reproductive autonomy.
Its withdrawal would be a policy failure and a regressive step for reproductive healthcare.
Alison Spillane is Policy and Research Officer with the Irish Family Planning Association and an Irish Research Council-funded PhD student at the School of Social Work and Social Policy, Trinity College Dublin.