Grey areas: The Republic of Ireland has seen widespread pro-choice lobbying. Now doctors in neighbouring Northern Ireland are gripped with uncertainty over what constitutes a legal abortion.
Medical staff in Northern Ireland are operating in a “climate of fear”, worried about the threat of imprisonment if they offer advice to women seeking an abortion, healthcare leaders have said.
The number of legal abortions being carried out in Northern Ireland has halved in the past two years because doctors and midwives have been alarmed by punitive draft guidelines, which state that healthcare workers risk life imprisonment for performing an unlawful abortion.
“There is a real sense of fear, and concern that one of us could end up in prison,” said Carolyn Bailie, of the Northern Ireland committee of the Royal College of Obstetricians and Gynaecologists. Doctors are too scared to provide information about clinics in England where women could seek an abortion because they are unsure whether giving even this very limited advice is illegal.
“It is difficult for us to advise our patients – if you offer them advice on who to contact, are you breaking the law? We don’t know. We are walking a legal tightrope,” said John O’Kelly, chair of the Royal College of General Practitioners in Northern Ireland.
The United Kingdom’s Abortion Act of 1967 was never extended to Northern Ireland. Abortion is available if “there is a risk of a real and serious adverse effect on a woman’s long-term physical or mental health”, but there is little clarity about what circumstances this clause embraces.
Because the law is so unclear, midwives say they are worried they may be committing a crime if they agree to help with an abortion. Some fear they could still be prosecuted for procedures they have assisted with in the past because of this legal uncertainty.
Consultant obstetricians and gynaecologists say they feel unable to provide women with adequate care, given the absence of official guidance on how to interpret the law. Alarmed by the recent discussion of punitive guidelines, most are now erring on the side of caution, forcing more women to travel across the Irish Sea for a termination, even in cases where an abortion might legally be permissible in Northern Ireland.
“Women in Northern Ireland are not getting the care that they really need because of the fear and confusion on the part of the healthcare team looking after them,” said Breedagh Hughes, director for Northern Ireland at the Royal College of Midwives.
The situation has become more confusing for healthcare staff in the past two years after the publication of draft guidelines by Northern Ireland’s health minister, Edwin Poots, in early 2013. “It is important for practitioners to appreciate that anyone who unlawfully performs a termination of pregnancy is liable to criminal prosecution with a maximum penalty of life imprisonment,” the document states.
Although these guidelines were subsequently withdrawn, doctors say they had a “chilling effect”, making staff very reluctant to provide abortions that might previously have been viewed as standard. New guidance has yet to be published.
Between 2012 and 2013, 51 clinical abortions were carried out legally in Northern Ireland, but by the following year the number had more than halved to 23. By contrast, more than 800 women travelled to England in 2014 for an abortion.
Doctors who had previously felt able to provide abortions to women who were carrying foetuses with fatal abnormalities say they no longer feel able to help those women. Instead, they advise them to travel to England for a termination.
Bailie added: “The law is very unclear, and it depends on the interpretation of the law. Rather than being managed locally with staff who have got to know them and can support them, with family close by, women are having to go to England and have the procedure there and then travel back.”
The discussion of the punitive guidance has frightened medical staff at all levels, said Hughes. “Before there was a spotlight being shone on it, the medics may have said: ‘I think this is probably lawful – a woman is in distress; we are going to offer her the option.’ There is no question of that happening now.”
Hospital doctors, midwives and general practitioners said they found it particularly difficult when women who were miscarrying after taking abortion pills bought online came to seek their advice, because of pressure to report anyone who has illegally procured an abortion.
One doctor recounted the unease he felt when a woman told him she had taken these pills. “It put me in an illegal position because, in the letter of the law, I should report her. Obviously, I’m not going to do that, but this is the sort of problem you get,” he said.
Nurses have also spoken of their anxiety about helping women who are panicking after taking abortion pills bought online. Hughes said: “That’s not a good situation to be managing. The midwives are thinking: ‘Oh dear God, do I have to report this woman to the police because she is in the middle of a criminal act here?’”
Hughes is worried about the rising number of women taking tablets bought over the internet without medical help. “As knitting needles and coat hangers became obsolete and passé, in the last couple of years abortion pills have become available on the internet,” she said. “We are very concerned that women are taking pills bought on the internet and taking them without any medical supervision.”
She fears that women might misinterpret dosage instructions. “If you are eight weeks pregnant and you buy the pills online, it says to take two twice a day. That’s fine. If you are 16 weeks pregnant and you work on the assumption that if you take two at eight weeks, you could take four at 16 weeks, that would do the job. That’s disastrous. That is our worry.”
Hughes understands how potent the sense of fear of prosecution is among medical staff. In 2008 she was interviewed at a police station, after telling a newspaper that over the course of her career she had been present at terminations and was not always sure whether the procedures were lawful or not. “Four hours of questioning was not pleasant.”
She was asked by police to supply the names of the patients and staff she had worked with, but refused to comply. The investigation was dropped owing to insufficient evidence.
Hughes said it is hard for midwives to judge when a procedure is legal. “Unless the doctor makes a written declaration to say that … this procedure meets the requirements of the law in Northern Ireland, midwives [can] live with the fear that something that has happened in the past may come back and haunt them.”
But the situation is confusing for doctors, too, Hughes added. “Are they meant to sit with the law books in the wee small hours of the night, and read the legislation and try to interpret it for themselves? What happens is they become fearful and they err on the side of caution. Those who have money travel to England and have an abortion and those who don’t have money stay in Northern Ireland and have babies.”
Bailie said there is optimism that constructive ongoing talks with the health minister will lead to greater clarity.
A spokesperson for the Northern Ireland health department said new guidance is under consideration but in the meantime, healthcare trusts should “ensure that any health professional has access to legal advice where it is considered to be needed in connection with a termination of pregnancy”. – © Guardian News & Media 2016