What the Law Looks Like in Practice: Reflections from a Hospital-Based Abortion Care Provider

When I began working in hospital-based abortion care several months ago, I expected to learn about medications, procedures and clinical decision-making. I did not expect to spend so much time thinking about the law.

Over the past several months, I have come to love this work. That may seem an unusual thing to say about a field that many assume is defined primarily by difficult circumstances, controversy or ethical complexity. What I have found instead is an area of women and pregnant people’s healthcare grounded in compassion, trust and respect.

Every week I meet women from every conceivable background. Their reasons for seeking an abortion are deeply personal and often shaped by complex relationships, financial pressures, caring responsibilities or health concerns. No two stories are the same, but what they all deserve is care that is free from judgement. One of the greatest privileges of this work is being able to offer that space.

Working in hospital-based abortion care has shown me just how law and medicine can intersect in troubling ways that exceptionalise abortion. Unlike almost any other area of clinical practice I have experienced, clinicians must constantly consider not only what is clinically appropriate, but also what is legally permissible. At each clinic, I see the impact legislation has on women’s experiences of seeking care, often in ways that are not immediately visible in policy debates.

The mandatory three-day waiting period requires women seeking an abortion before 12 weeks to attend an initial consultation and then wait at least three days before treatment could proceed. In a hospital-based service, where we often care for women with more complex circumstances and women presenting later in the first trimester, navigating this requirement can be particularly challenging. While some justify it as a safeguard, I rarely see it alter a woman’s decision. Instead, it often creates additional barriers for those already facing the greatest challenges: women in difficult social circumstances, those experiencing domestic abuse, women juggling insecure employment who struggle to take time off work twice, women experiencing housing instability or substance use difficulties, or those who have already struggled to access services.

What became increasingly apparent to me was that the law, however well intended, did not affect every pregnant person equally. Those with the greatest social, financial or practical barriers were often those most affected by legal requirements that, on paper, applied equally to everyone.

For many patients, the time for reflection has occurred long before they reached our clinic. The waiting period frequently feels less like a protection and more like an obstacle. Its proposed removal is a welcome recognition that women can make informed decisions about their own healthcare and that clinicians can support those who need additional time without imposing a blanket legal requirement on everyone.

Another issue that continues to concern me is the management of failed early medical abortion. Although early medical abortion is highly effective, no treatment is infallible. On rare occasions, despite taking medications appropriately and following recommended care pathways, a pregnancy continues. By the time this is recognised, some women have passed the 12-week legal threshold through no fault of their own.

These cases are uncommon, but when they do occur they can be devastating for the women involved. A woman who sought care within the legal timeframe and followed medical advice can suddenly find herself facing an impossible situation. Depending on when the ongoing pregnancy is diagnosed, she may have to consider travelling abroad to complete the abortion at a later gestation, when the physical and emotional burdens are greater and the procedure carries higher risks. Alternatively, she may feel compelled to continue a pregnancy that has been exposed to abortion medications.

There is also an important clinical concern. When a pregnancy continues after exposure to abortion medications, clinicians must counsel women about the uncertainties surrounding fetal exposure and the potential risk of fetal anomalies. This creates an ethical dilemma. We are left caring for women who accessed lawful treatment appropriately, yet because that treatment has failed, we may be managing the unintended consequences of an intervention we initiated. As a clinician, I find it difficult to reconcile that a woman who sought care within the legal timeframe and followed medical advice may be unable to complete the care she had already lawfully sought simply because of a recognised medical complication.

As my time working in abortion care has progressed, I have realised that legislation is never abstract. It shapes clinical encounters, influences patient outcomes and creates unintended consequences that only become apparent in practice. The proposed removal of the mandatory three-day waiting period is an example of the law evolving in response to lived experience. The ongoing challenges surrounding failed medical abortion suggest there is still further work to do.

My belief is that abortion care is simply healthcare: it should be guided by evidence, compassion and respect for patients.

My experience to date has made me appreciate the unique position of clinicians working in abortion care. We are asked to navigate one of the few areas of medicine where clinical decision-making remains closely intertwined with criminal law. The potential for criminal liability if that legal framework is breached is unlike anything else I have encountered in my medical training and inevitably shapes the way clinicians approach this work.

Looking back over the past several months, what has struck me most is that abortion care is one of the few areas of medicine where the law sits quietly in every consultation. It shapes the conversations we have, the decisions we make and the care we are able to provide.

Good law, like good medicine, should be informed by the realities of clinical care.

As Ireland’s abortion legislation continues to evolve, I hope it will continue to do so with the experiences of the women and pregnant people who use these services—and the clinicians who provide them—at its heart.

Molly Walsh is an Obstetrics and Gynaecology Specialist Registrar and Fellow in Abortion Care at the Coombe Hospital, Ireland.