Article Text
PDF
Abstract
Introduction Abortion became decriminalised in Northern Ireland in October 2019. Until that point there existed no evidence concerning the views of health professionals on decriminalisation or on their willingness to be involved in abortion care. The purpose of this study was to address this lack of evidence, including all categories of health professionals working in obstetrics and gynaecology units in Northern Ireland.
Methods The online survey was targeted at medical, nursing and midwifery staff working in the obstetrics and gynaecology units in each Health and Social Care (HSC) Trust in Northern Ireland. The survey was issued via clinical directors in each Trust using the REDCap platform.
Results The findings showed widespread support for decriminalisation of abortion up until 24 weeks’ gestation (n=169, 54%). The majority of clinicians stated they were willing to provide abortions in certain circumstances (which were undefined) (n=188, 60% medical abortions; n=157, 50% surgical abortions). Despite regional variation, the results show that there are sufficient numbers of clinicians to provide a service within each HSC Trust. The results indicate that many clinicians who report a religious affiliation are also supportive of decriminalisation (n=46, 51% Catholic; n=53, 45% Protestant) and are willing to provide care, countering the assumption that those of faith would all raise conscientious objections to service provision.
Conclusions The findings of this study are very encouraging for the development, implementation and delivery of local abortion care within HSC Trusts in Northern Ireland and should be of value in informing commissioners and providers about the design of a service model and its underpinning training programmes.
- abortion
- induced
- surveys and questionnaires
Data availability statement
Data are available upon reasonable request. Once authors complete analysis the dataset will be archived at the UK Data Archive at the University of Essex and will be accessible by academic researchers. All data will be anonymised so that participants cannot be identified.
Statistics from Altmetric.com
Key messages
The majority of responding clinical staff working in Northern Ireland’s obstetrics and gynaecology units support decriminalisation of abortion up to 24 weeks’ gestation.
There is willingness among clinical staff to participate in medical and surgical abortion in ‘certain circumstances’ (which were undefined).
The findings suggest favourable professional conditions for the development and implementation of abortion services within Health and Social Care Trusts in Northern Ireland.
Introduction
Abortion in Northern Ireland became decriminalised in October 2019 following a lengthy campaign, court cases, and international and national inquiries.1 Specifically, the decriminalisation of abortion as set out in the Northern Ireland (Executive Formation etc) Act 2019 formed part of the requirements of the United Nations Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) inquiry into abortion access published in 2018.2 3 This historical change had been preceded in 2018 by reform of abortion laws in the Republic of Ireland, resulting in the repeal of the Eighth Amendment to the Constitution of Ireland which had equated fetal rights with that of the pregnant person.4 In Northern Ireland, prior to October 2019, the criminalisation of abortion coupled with stigmatisation had resulted in an average of 1000 women/pregnant people each year travelling to other jurisdictions in the UK to access abortion services, hundreds aborting at home after self-medication, with fewer than 20 abortions each year being carried out within Northern Ireland under the restrictive law.5–7 Pre-decriminalisation, abortion was permitted when the woman’s long-term health and well-being, or her life, were at risk; these abortions were carried out by doctors in hospital settings or within a Marie Stopes clinic.1 5 Post-decriminalisation, The Abortion (Northern Ireland) Regulations 2020 allowed for abortion without restriction up until 12 weeks of gestation, with conditions applying thereafter. Abortions can be provided by a range of health professionals in healthcare settings.8 Since the publication of the Regulations, medical abortions have been provided on an interim basis in sexual and reproductive health (SRH) clinics within Health and Social Care (HSC) Trusts. Due to the absence of commissioning, abortion services are restricted to early medical abortion, or on grounds of fetal abnormality. Those women not meeting the conditions are required to access services elsewhere in the UK.9
Pre-decriminalisation, illegal abortions were accessed via online providers of telemedicine abortion. The exact extent of this is unknown, but is estimated to be several hundred per year.1 7 Post-decriminalisation, these services have continued for those who are unable to travel to a SRH clinic. Telemedicine abortion via the National Health Service (NHS) has not been introduced during the COVID-19 pandemic, unlike in the rest of the UK.9
Previous studies have explored the views of medical staff in Northern Ireland as to their opinion on legal reform, identifying that most favoured legal change.10 11 Pre-decriminalisation health professionals had indicated awareness of resistance within some HSC Trusts regarding implementation of abortion services, reflecting the differing staff demographics within each with regard to religion and urban versus rural influences.12 One all-Ireland workplace study indicated that those with no religious affiliations were more supportive of abortion provision than those from Catholic and Protestant affiliations; however, the number of health professionals within this study was small.13 There is no evidence concerning the views of health professionals on decriminalisation or on their willingness to be involved in abortion care, nor have studies captured the views of midwives and other professional groups working in obstetrics and gynaecology services.
The purpose of this study was to address this lack of evidence, including all categories of health professionals working in obstetrics and gynaecology units in Northern Ireland. This sample was chosen as these units were expected to provide abortion services in the period immediately following decriminalisation. We hypothesised that there would be general support for decriminalisation, and willingness to deliver services, and that this would vary between HSC Trust areas, and within age, gender and religion subgroups.
Methods
We performed a cross-sectional descriptive study from 1 October 2019 to 31 January 2020, assessing support for decriminalisation and willingness to deliver abortion services in Northern Ireland. The study was conducted by Ulster University in partnership with University College London (UCL) Medical School. Ethical approval was provided by UCL Medical School. The survey was administered through REDCap, a secure, web-based application. Data were transferred to SPSS (Statistical Package for the Social Sciences) for analysis. Health professionals were eligible to participate if they were at least 18 years old, spoke English and were working in an obstetrics and gynaecology unit in the NHS in Northern Ireland. Those unwilling or unable to consent were excluded. Consent to participate was anonymously requested. Each survey was given a unique study number, and no identifying information was collected.
Recruitment to the study was a two-stage process. First, the Northern Ireland office of the Royal College of Obstetricians and Gynaecologists (RCOG) issued a letter to clinical directors in the five HSC Trusts, informing them of the study. In the second stage, clinical directors were asked to send the survey to staff who met the criteria. As midwifery uptake was low in the first 2 weeks, the Northern Ireland office of the Royal College of Midwives (RCM) issued the survey directly to members. The response rate for the survey varied between professional groups, with 61% for RCOG and 20% for RCM. Responses with missing data were excluded from the analysis.
The survey included questions on demographics (such as age, gender and religion), which professional group the respondent belonged to, which HSC Trust they worked in, and their awareness of, and views on, decriminalisation (see online supplemental appendix 1). A total of 18 questions were asked. Most were closed questions with an option to provide a narrative explaining the reason for the choice of answer. The survey took 10–20 minutes to complete, depending on whether responses were given to the narrative questions. Regarding questions on willingness to provide services, the phrasing ‘certain circumstances’ and ‘all circumstances’ was used; these were left undefined, with respondents encouraged to explain their views in the narrative that followed.
Supplemental material
We used descriptive and bivariate statistics. Chi-square tests, which are suited to small cell sizes, were applied to determine if there was an association between support for decriminalisation and willingness to deliver services with the outcome variables being HSC Trust, age, gender and religion.
Patient and public involvement
The primary focus was on the views of health professionals and so patients were not involved in the design or development of this study.
Results
Profile of respondents
Of the 312 respondents, 113 (36%) were obstetricians/gynaecologists and 112 (36%) were midwives, with the remainder comprising anaesthetists, gynaecology ward nurses, theatre nurses, SRH doctors and nurses, and early pregnancy assessment nurses.
In terms of religious affiliation, respondents were split between three main categories: Protestant (117, 37%), Catholic (90, 29%) and Other (29, 9%). Sixty-two (20%) respondents reported no religious affiliation, and the remaining 16 (5%) preferred not to state their affinity.
The vast majority of respondents were women (256, 82%). With respect to age, there was a broad distribution of respondents in all age categories: 36 (11%) aged 18–29, 92 (30%) aged 30–39, 73 (23%) aged 40–49, and 111 (26%) aged 50+ years.
In the analysis that follows, we take each of the outcome variables and cross-tabulate with responses to three key questions: (1) whether respondents were in favour of decriminalisation of abortion, with the understanding that the limit would be 24 weeks’ gestation; (2) whether respondents were willing to actively participate in medical abortion of pregnancy in certain circumstances; and (3) whether respondents were willing to actively participate in surgical abortion of pregnancy in certain circumstances.
Views on abortion issues
In relation to respondents’ views on decriminalisation of abortion, with the understanding that the limit would be 24 weeks’ gestation, 169 (54%) were in favour.
Analysis indicates that there is evidence of a strong relationship between views on decriminalisation and HSC Trust area (p<0.05) (table 1), with over half of those in the Belfast Health and Social Care Trust (BHSCT), the Western Health and Social Care Trust (WHSCT) and the South Eastern Health and Social Care Trust (SEHSCT) being in favour of decriminalisation. In comparison, fewer than 50% of respondents in the Northern Health and Social Care Trust (NHSCT) and the Southern Health and Social Care Trust (SHSCT) held the same view.
Survey results by Health and Social Care Trust area
The majority of respondents (188, 60%) were willing to actively participate in medical abortion of pregnancy in certain circumstances, 105 (34%) were not and 19 (6%) were unsure. There was no evidence of a strong relationship between views on medical abortion and HSC Trust area (table 1).
Half of the respondents were willing to actively participate in surgical abortion of pregnancy in certain circumstances, 127 (41%) were not and 28 (9%) were unsure. There was no evidence of a strong relationship between views on surgical abortion and HSC Trust area (table 1).
In considering respondents’ religious affiliation and their views on the three questions, there is very strong evidence of a relationship between religion and opinion on decriminalisation (p<0.01) (table 2). There is also strong evidence of a relationship between religion and willingness to participate in medical abortion (p<0.02) and surgical abortion (p<0.01). It is clear that those with no religious affinity are more likely to favour decriminalisation, and be more willing to participate in medical and surgical abortions, than their peers who had declared a religious affinity. Respondents from the Catholic community were more likely to be in favour of decriminalisation and to be willing to participate in medical abortion than those from the Protestant community. Notably, both groups of respondents held similar views on willingness to participate in surgical abortion.
Survey results by religious affiliation
Analysis of the age group of respondents with respect to views on decriminalisation and willingness to participate in medical and surgical abortions indicates variation (though no strong relationship); fewer than 40% of those aged 18–29 years were in favour of decriminalisation, while over 50% of those in the remaining age groups held the same view.
Table 3 illustrates responses categorised by gender. Just over half of the respondents who identified as women favoured decriminalisation compared with almost three-quarters of men (p<0.05). Similar differences were noted regarding willingness to participate in medical abortion (p<0.05) and surgical abortion (p<0.10). Overall, analysis indicates a relationship between gender and responses to these questions, though the small numbers in this category warrant caution.
Survey results by gender
In relation to professional group, we analysed the data after grouping together the following categories: anaesthetists/theatre nurses, gynaecology ward nurses, early pregnancy assessment service nurses/midwives, obstetricians/gynaecologists and SRH doctors/nurses. This allowed for ease of analysis of categories with smaller numbers. Between the professional groups we observed clear differences in response to each of the three questions (table 4). Analysis indicates a strong relationship between professional group and responses to these questions. While two-thirds of obstetricians/gynaecologists and over 50% of anaesthetists/theatre nurses favoured decriminalisation, less than half of the midwives did. Gynaecology nurses were least in favour of decriminalisation (p<0.01). Similar patterns were observed in relation to willingness to participate in medical (p<0.01) and surgical (p<0.01) abortions. SRH staff were the least willing to participate in both.
Survey results by professional group
Discussion
Setting the findings of this study in the wider literature, it is evident that the views of health professionals in Northern Ireland over the last decade have remained supportive of widening access to abortion and reform of the previously restricted legal framework.10 11 The results also reflect public support for decriminalisation of abortion, nationally and internationally.3
The study findings indicate support from the majority of responding clinical staff working in Northern Ireland’s obstetrics and gynaecology units for decriminalisation of abortion up until 24 weeks’ gestation. Support for decriminalisation is particularly prevalent among obstetricians and gynaecologists, a factor which favours the development of future abortion services within maternity and gynaecology units, although with the caveat that support may be less forthcoming from midwives and gynaecology nursing staff. It is noteworthy that the support for decriminalisation up until 24 weeks’ gestation extends beyond the abortion regulations, which limited access beyond 12 weeks.8 The findings would suggest that abortion beyond 12 weeks’ gestation would be acceptable to clinicians.
While least support was found among SRH clinicians, it is worth noting that early medical abortion services are currently provided within SRH clinics across the HSC Trusts.7 These were rapidly set up, without funding, in order to address the need for local abortion provision during the COVID-19 pandemic. These meet a substantial proportion of the population's need, providing short waiting times and post-abortion contraception, and they have received very positive patient feedback. This demonstrates that a high-quality regional service can be delivered by relatively small numbers of staff when those participating are committed to the provision of safe, compassionate abortion care.
Encouragingly, there is a willingness among obstetricians and gynaecologists, anaesthetists and theatre nurses to participate in surgical abortion in certain circumstances. This suggests favourable conditions for the development and implementation of a surgical abortion service within Northern Ireland. Although there has been progress towards standardisation and a regional approach to healthcare, HSC Trusts have retained their own identities and cultures, and the regional variation in responses reflects the differing staff demographics within the Trusts. However, despite regional variation, the results indicate that there are sufficient numbers of clinicians to provide a service within each HSC Trust.
While there is an incontrovertible link between religion and conscientious objection, there is evidence that many who report a religious affiliation are supportive of decriminalisation and are willing to provide care. Evidently there is an religious influence on healthcare provision within Northern Ireland. It would be prudent for HSC Trust managers to discuss with staff their views on abortion and whether they intend to opt out of any aspects of abortion care, in order to inform service planning and development at a local level. These discussions should have sufficient detail to indicate what procedures or processes an individual is comfortable with, and what they are not comfortable with.
There is a need to provide education and training to clinicians in Northern Ireland who may encounter a patient at any point along the pathway to choosing and accessing an abortion. This is important both for mitigating abortion stigma and ensuring that women are treated with compassion and respect, and for ensuring that the skills of clinicians are of a requisite standard.
It is of relevance that the survey was undertaken prior to publication of The Abortion (Northern Ireland) Regulations 2020.8 These regulations allow for abortion to be provided within HSC Trusts and within general medical practices. A limitation of the study is that the views of general practitioners (GPs) were not sought. Nor were views sought on specific models of abortion care, such as GP provision, or provision within integrated SRH health services, such as the interim service currently in place.
Future research is needed to assess the views of GPs and to ascertain which models of care may work best in the Northern Ireland context. Nonetheless, the findings of this study are very encouraging for the development, implementation and delivery of local abortion care within HSC Trusts in Northern Ireland, and should go a long way towards informing commissioners and providers in the design of a service model and its underpinning training programmes.
Data availability statement
Data are available upon reasonable request. Once authors complete analysis the dataset will be archived at the UK Data Archive at the University of Essex and will be accessible by academic researchers. All data will be anonymised so that participants cannot be identified.
Ethics statements
Patient consent for publication
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors FB conducted the analysis. FB, LM and RR were responsible for the initial drafting of the manuscript and the final edits and revisions. FB, RR, CF, JK and LL carried out interim revisions and edits.
Funding The study was funded by the Open Society Foundation.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.