My interest in the legal witnessing project is driven by my lived experience as a general practitioner (GP) providing abortion care in Ireland since 2019, and by my knowledge of the challenges faced by GP abortion care providers within the Southern Task Group on Abortion and Reproductive Topics (START). I know GPs spend a great deal of time and energy working to reduce the harmful effects of abortion restrictions, while navigating the legal framework and extending the benefits of routine reproductive healthcare within legal boundaries. This causes significant displaced capacity within general practice, diverting clinical time, expertise and resources away from other areas of patient care.
When the legal abortion service was first implemented in 2019, providers were informed that the strict 12-week gestation limit (interpreted in this case as 12 weeks plus zero days, rather than the traditional obstetric interpretation of 12 weeks up to 12+6 days) would apply universally under section 12 of the Health (Regulation of Termination of Pregnancy) Act 2018. Indeed the HSE consent form for early medical abortion (EMA) explicitly states: “If my abortion fails and I have an ongoing pregnancy that goes beyond 12 weeks of pregnancy, it is illegal for a doctor to provide an abortion unless there is a risk to life or health, risk to life or health in emergency, or condition likely to lead to death of the foetus.” Such blunt rules and fearful language do not sit well with a commitment to making public reproductive healthcare the best it can be.
The vast majority of abortions carried out in Ireland under section 12 are medical. Early medical abortion is a process that begins at a particular point in time but does not necessarily end at a predictable point in time. The strict time-limit for completion of pregnancy termination creates a fundamental mismatch between the way abortion is delivered in practice and the way it is framed in law. EMA rarely fails (typically 1–2% of cases), but when it does occur it is distressing for a woman who has begun the process in good faith within the legal time-frame. She is still pregnant having taken medication to end her pregnancy, and if the gestation exceeds 12 weeks at the time of confirmation of failed EMA, she is left with no legal pathway to further care within the jurisdiction. Most women have to travel or continue with their pregnancy.
This is also a disturbing for the provider, who has given medication with a known teratogenic risk to the foetus. The prospect of this scenario has far-reaching effects beyond the instances when it actually occurs – it has a chilling effect on all those who are warned, or have to warn, that there may be no follow-on abortion care available in this jurisdiction for someone who has initiated a lawful early medical abortion under s. 12 but has an ongoing pregnancy beyond 12 weeks gestation.
Prior to attending the workshop, I carried out an informal poll of GP providers in the START group. I received 80 replies, of those who responded:
- 18% (14) had encountered a case in their clinical practice where EMA was initiated <12 weeks but failed, and the patient exceeded the legal gestational limit before completion.
- 64% (51) had not directly encountered this, but had experienced a near miss or concern that it could have happened.
- 85% (68) said that the 12-week legal limit, including the 3-day wait, influenced their clinical decision-making near the gestational threshold.
- 72% (56) said they thought this scenario creates a “chilling effect” on providers and/or patients, for example through earlier intervention than clinically necessary, increased anxiety or altered counselling.
In the free-text responses, providers gave details of how fear of exceeding the strict 12 week window resulted in increased visits and/or increased investigations, including scans and blood tests, for women attending.
One provider said:
“I have had to refer to UK for one woman who was very shocked. She had very little supports and thankfully was financially secure enough to be able to travel at low notice. Her sadness and shock at how far along she was and the lack of care we could offer was heartbreaking and traumatising for her and myself as a provider.”
Another highlighted the disconnect between front-line service operations and the rigid legal timeframe:
“I had a failed EMA. She was approaching the 12 week limit. 2 out of the 3 Dublin hospitals wouldn’t/couldn’t see her before her 12 week gestation. Thankfully one hospital saw her at 12 weeks and she was treated. It was a horrible experience for all! A lot of admin time. Thankfully we have resources but not all primary care do.”
One provider highlighted how the prospect of a failure going beyond 12 weeks can overshadow care right from the beginning of the abortion process:
“I also try and counsel women who are uncertain re the time limit but it can be hard to balance informing them and feeling that you’re putting them under pressure to make a decision.”
Community providers of EMA feel the pressure of the possibility of failed EMA from the very first contact. The fact that this service is couched within criminal law brings this into even sharper focus for us and for our patients.
The issue is therefore not simply the small number of cases in which an EMA fails after treatment has been initiated. The impact of the strict legal timeframe is much broader. The possibility of this outcome influences clinical decision-making, counselling, investigations, referrals and the experience of both patients and providers.
For providers, knowing that a woman may be left without a legal pathway to care if an EMA fails and the pregnancy passes the 12-week limit creates anxiety and uncertainty from the outset. For patients, this can translate into pressure, increased anxiety and, in some cases, the need to travel outside the jurisdiction at a time when they are already distressed.
This is the lived experience of providing EMA within the current legal framework and related clinical guidelines, and it is an important consideration when examining the impact of the 12-week gestational limit.
Dr Trish Horgan MCN 20088 GP Provider of EMA and founder member of START.
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