Abortion provision in Ireland: Implementation and advocacy,an Irish and international perspective from practice

Abstract

Dr Mary Favier is a General Practitioner [GP] with longstanding history of advocacy for abortion care in Ireland. Following Repeal, GPs committed to realising abortion care came together to design a model for medication abortion provision through Primary ¹ care in Ireland. The group presented this model of care design to the Department of Health who agreed that the model was a good fit for implementing abortion provision in Ireland following Repeal. To this extent, the model of abortion care could be considered as co-designed. With the help of international collaborators, supporting resources and infrastructure were developed organically. In this interview, the role of Primary Care in the ongoing management and governance infrastructure of the service is highlighted, and it is argued that despite providing the majority of abortion care in Ireland, representation of GPs has been sidelined.

Body of the paper

Catherine: Dr Mary Favier. You are a GP in Cork, and we are here to discuss the paper that you contributed to the After the Review. What Next for Abortion Services in Ireland? Conference, held in Trinity College, Dublin, in October 2023. We are capturing your presentation at the conference, which was a reflection on practice in an interview format, to contribute to the Irish Journal of Sociology Special Issue.

Mary you are a co-founder of Doctors for Choice, Co-founder of the START (Southern Taskforce for Abortion and Reproductive Topics) providers group, Co-chair of Global Doctors for Choice and an Early Medical Abortion GP provider and trainer. At the Conference, you presented a paper on Abortion Provision in Ireland – Implementation and Advocacy. A perspective from practice. We're having a conversation today to capture that paper because when the Call for Papers issued your first response was that, as a provider, you could not envisage getting the time to prepare a traditional academic paper manuscript. Meanwhile, as Conference convenors and Special Issue editors, we were concerned that this would mean the practice perspective that is so crucial to the multi-disciplinarity and multi-stakeholder dynamic that set the conference apart would be missing. This format was then identified as a means to facilitate the inclusion of the practitioner perspective.

Catherine: Let's start by capturing your account of the role GPs played in that very short timeframe of six to seven months after the Repeal of the Eighth Amendment to design, plan, and implement an abortion service for the Irish health system by 1 January 2019. What is the role GPs played in implementation and advocacy – the role Doctors for Choice Ireland and START GPs took up from that point?

Mary: On the day of the Repeal vote and the next day after the vote count, I think the most notable thing was, well, first of all, everybody in the whole advocacy area was delighted, jubilant, and thrilled. It was a phenomenal amount of hard work, and we were all exhausted, but what was apparent, and we as Doctors for Choice had known beforehand, was that the design and implementation of the service was going to be an immediate, big challenge. There had been an earlier government commitment to legislate for and implement any new service quickly, as stated on the first of January 2019. We had now just seven months to get to that date, to assist in getting the service up and running and across the line, without a clear path as to what role GPs were going to play in the design and delivery of the service. We were aware that we were significant participants and were likely to be the providers of the service, and therefore we had a significant role in the development of ideas around what the service should look like.

Coincidentally, the day after the vote was passed, the Annual General Meeting of the Irish College of GPs was held, where I became Vice President of the College of GPs, and a year later, President. So, it coincided with me taking on a nationally representative role in general practice. I’d been on the board of the ICGP before that and had spent many years involved in the ICGP, mainly in education roles. My new role coincided with the development, design, and implementation of the early medical abortion service. In reality, very little happened over that summer, in June, July, into August of 2018. I think it was a combination of everybody was exhausted, and I think politically, people were exhausted as well, including in the government. And it was really only into August, September that things started to really get going again and thinking, okay, we now have a four-month deadline, we've got to get our act together and on from there.

Catherine: When you say ‘we,’ Mary, who was the ‘we’ at that point?

Mary: In the broadest sense the ‘we’ was the Department of Health contacting the Irish College of General Practitioners (ICGP), and Doctors for Choice saying we know we need to start a service, We need to start to work with you, We need to start to design that service, and that GP assistance was needed to understand, design and implement it, and then initial meetings from there. In the background, politicians were working around passing the enabling legislation. The legislation was passed in late December 2018, when the President signed it into law. So, the design work had to go on in parallel, with no actual knowledge that the law was going to pass. It was probably never really in doubt, but what exactly we would get was never entirely clear until the end.

Catherine: Can you describe what, if any, work had been done on the development of this service pre-Repeal?

Mary: Doctors for Choice had put a lot of effort into the two years before Repeal, thinking through the design of the potential new service. There had been very significant assumptions, presumptions by everybody, including most doctors, that Ireland would have a service that mirrored the UK's, England and Wales, clinic-based service. This is basically a clinic-based service. There, the National Health Service (NHS) subcontracts the provision of its abortion service almost entirely (with the exception of Scotland) to the NGO private sector of charities, which are largely the British Pregnancy Advisory Service and Marie Stopes, with some others. And there was a presumption that we would just do a version of the same thing here, and there was even talk that we might subcontract to those UK charities to come into Ireland to provide abortion services here – and there was some enthusiasm for that. But when we as doctors, and particularly GPs, thought it through, there were so many problems and barriers with that potential service. Because Ireland is a small country – the population is about 5 million – in reality, we could probably only have four or five clinics across the country. You might get two in Dublin, one in Galway, Limerick, Cork, and, if you were very lucky, you might get one in Waterford. So, by definition, women would have to travel quite considerable distances for care. The clinics would be so visible and apparent they could become very particular lightning rods for potential protests. They would potentially act as a place for the anti-choice groups to reorganise and protest. It was an obvious way to effectively sabotage any new service by making it difficult to start, or difficult to work in, but most particularly difficult to attend. So, we were thinking about and grappling with all of that.

During that time, I had been involved with Global Doctors for Choice, where I had the privilege of having extraordinary access to all the people doing the latest research and implementation of abortion services, particularly early medication abortion. Pre-Repeal, a very significant number of women in Ireland were accessing medication abortion through internet-based services, for instance, Women on Web and Women Help Women. We knew that over a thousand women in Ireland were accessing this service each year pre-Repeal. There were very little complications and problems from this, and all the international literature supported that medication abortion was a very safe procedure, even in a low-resource, low-medical-supervision environment. So that got us thinking that we as GPs could provide a similar medication abortion service in Ireland.

But a nationally implemented community-based abortion service provided across primary care hadn’t been done anywhere else. There are pockets of primary care provision in France, there's pockets in Australia, there's pockets in Canada where GP family physicians provide an early medical abortion service, but it's within the subtext of a specialty interest; that is there would be sub-specialty GPs who would provide that service or would have a particular interest in the area. I looked at all the different places it's provided and looked at the particular difficulties and challenges they had. I spoke with many obstetrician/gynaecologists in various countries who provided these types of services. I talked to people who were doing research on it. I tried to design a sort of road test and stress test of what a primary care model would look like in Ireland and designed a community-based model using all that information.

And for the two years before Repeal, any time Doctors for Choice had a public speaking opportunity, we always tried to describe and promote what a GP-led, community-based service would look like. We particularly described it to the advocacy organisations so that they understood the problems with the clinic-based model in the Irish circumstances and that there was potentially another model. That it could be done differently. And of course, they understood very quickly the problems with the clinic-based model, in the Irish circumstances. To be fair to them, they trusted us that we knew what we were talking about, that we weren't potentially going to suggest a problematic or unsafe service.

Catherine: What other work had been done pre-Repeal?

Mary: Doctors for Choice had done a very significant mapping exercise of all the potential players you might need to involve in the implementation of a service. So that's everybody from the Health Service Executive (HSE), the Department of Health, the Chief Medical Officer; it's your academic colleges, both general practitioner and obstetric; it's the pharmaceutical supplier side, licensing; it's about unions (as it will bring changes to the terms and conditions in terms of people's work practices), remuneration, a new provision contract; the Medical Council – all those pieces and all the parts that might need to work together.

Catherine: How did all these groups, Doctors for Choice, the Department of Health, the Irish College of GPs, and abortion advocacy associations, come to consensus on GP-provided community-based care?

Mary: The Irish College of GPs was approached by the Department of Health to start to talk about a possible new service, and as the Vice President of the college I was strategically placed to bring in Doctors for Choice and our preliminary research.

The Irish College of GPs were initially very distrustful because, understandably, they haven't heard about GP provision as an alternative to a clinic service and hadn’t engaged with the idea that GPs would provide a community-based service.

The Department of Health recognised that they had a really big potential problem with the clinic model. And the political individuals, like the Minister for Health at the time, Simon Harris, quickly realised that we could quickly go from a significant victory to a pyrrhic victory, a potentially damaging political outcome. I could advise them of the many examples internationally where that is what has happened. Places like South Africa that has strong human rights-based abortion legislation and one of the poorest provision of services. I could also point them to a study that I had co-authored with Global Doctors for Choice and the World Health Organization (WHO), where we had surveyed six countries that had implemented new legislation in the previous 10 years and what their learnings had been (Chavkin et al., 2018).

Catherine: Could you tell me more about that study?

Mary: That study came about because of a question I had posed to Wendy Chavkin, a professor of Obstetrics and Gynaecology in the Mailman School of Public Health at Columbia University, New York, and one of the founders of Global Doctors for Choice. In conversation, I asked her did she know if there was any information, research evidence, or publications around the learnings of countries who had had new services and their implementation. After a literature search, we learned that there was no published evidence on it. With sponsor support from the World Health Organization, we designed a study to look at the most recent six countries to implement abortion services.

The study was published as an International Federation of Gynaecology and Obstetrics (FIGO) supplement (Chavkin et al., 2018). The learnings came down to three main strands. First, you must engage all the key stakeholders to understand exactly what's needed – a commitment to an ongoing, rolling implementation that it isn't a once off, because otherwise it will fail. Second, there must be an absolute commitment to provide education and values clarification in all environments where the service is provided. Not only around obstetrics and gynaecology, but also everybody who works in hospitals, even down to the purchasing officer and the person who does the roster. This again can't be once off, it must be ongoing. And, thirdly, that you must address conscientious objection straight on, straight up, and on a continuous and rolling basis. The biggest barrier to services internationally is around conscientious objection, effectively gaining legs and becoming obstruction. Similarly, but on the other end of the spectrum, is a convenient objection not against the service, but it's the power of stasis. It's just easier not to change anything, it's easier not to do things when we're all overworked, undervalued, whatever are the other issues in your health service. That's one of the biggest challenges always. And you can see that in the North of Ireland, as part of the problem, that it's just difficult when you're very overworked.

Catherine: How did you apply the learnings from this study?

Mary: Because I had taken part in the research, and I had done the South African arm, I had a very strong sense of what Ireland needed to do and what was needed to achieve success. In Doctors for Choice we had done a lot of the work talking to stakeholders and trying to get them to understand the community-based service and were well used to presenting the concept. So, I can remember the first meeting the ICGP had with the Department of Health and one official asked the college, how do you think the service could run? And me taking the opportunity to fill the pause that resulted to present our model. And effectively, from that date the community-based model was at the forefront.

Catherine: The ICGP were invited in on their own into the Department of Health?

Mary: We were not on our own the first time. I think the Institute of Obstetricians, the Medical Council, and somebody from the Health Products Regulatory Authority (HPRA) were there. But nobody really had any idea how to organise the primary care, general practice type service. And so, we filled that void, really.

Catherine: And what was your role in the ICPG at this time?

Mary: I was Vice President of the ICGP for that stage. And I also represented Doctors for Choice, as everyone in the room would have known from the media in the referendum. I was there accompanying the President of the ICGP and the Medical Director. The Vice President wouldn’t normally attend such a meeting, but they asked me as they knew they needed an expert about the subject. But the college was always very wary of Doctors for Choice and had previously kept an absolute arm's length from us.

Catherine: Can you speak more about that?

Mary: The ICGP was conservative and had always presumed an anti-abortion stance before Repeal. In the months following Repeal they had to grapple with an alternative view of both the Irish people and a now legitimised position of many of their GP members. The history was that the ICGP structures had objected strongly every time Doctors for Choice had tried to put a motion to an Annual General Meeting to change the anti-choice stance. ICGP had obstructed Doctors for Choice when we had to tried to hand out an information leaflet or put up a stand at a meeting. So, some were less than pleased that I was the Vice President, and hyper-cautious that anything with the name Doctors for Choice should ever be associated with the College, because they were worried about what membership would say. So, it was very convenient that I could have another hat of Vice President and the Department, and the College could access the expertise of Doctors for Choice that way, kind of through the backdoor.

Of note, I had been on the board of the ICGP for about five years, had completed an earlier term as Chair of Education, and had had multiple other roles in the college – I had a big history in ICGP. So, it was quite funny, because the ICGP didn't ever mention that I was in Doctors for Choice if I was doing anything official, but they were very happy to lean into the expertise after Repeal.

Catherine: Yes, so Repeal had given this area of health care a new legitimacy. And you, by virtue of a happy confluence of events, happened to be in the role of Vice President of the ICGP through Repeal and you had been doing this background work around a model of abortion care.

Mary: Yes. I became the public-facing lead of community-based abortion care. I was sent to the Oireachtas Health Committee hearings, along with other ICGP leadership such as the President or the Chair in support, through the end of the year in 2018.

Catherine: Had you other colleagues within the GP profession that you could liaise with both Irish and international?

Mary: Yes. Doctors for Choice was a broad group, not just GPs, and had a very strong, active committee of all the people who'd worked up to Repeal, but particularly as GPs. With [other GP colleagues], we'd been very much sort of road testing the idea of community-based abortion care and I had been bouncing ideas off other members, did they think this could work? What were the pros and cons? We talked about it a lot in Doctors for Choice. At one stage, we were having weekly meetings coming up to Repeal, and we would talk about some aspect of the possible service provision and possible snags, and how do we think we’d get around them, at every single meeting. For instance, in our preliminary discussions, we had tried to follow the patient journey of how women would access a general practitioner. How the GP would access the medications. Would there be prescriptions given to the patient?

One of the issues we quickly came up with was it wouldn't work if women had to walk into the reception of their GP and ask across the desk for the service. We were saying, we’re going to need some sort of telephone service, some sort of helpline. We had referenced the time of the stickers on the backs of the toilet doors, back in the day, when you couldn't access any services. We had got that far in our thinking when we ended up meeting with the working group of the Department of Health. They very quickly understood the potential problem. I can remember saying this to Simon Harris [Minister for Health] at one of these meetings, and the sort of look of horror on his face at the idea that women would have to run the gauntlet of trying to find a GP to provide the service, being rejected, judged, shamed and turned away.

The Department of Health then came up with the idea of the MyOptions service (a freephone helpline to connect patients to abortion care services), using the One Family model that had been there from the HSE Crisis Pregnancy Programme. To be fair to them, they really ran with it, and it really worked. They did a huge amount of work on this with the ICGP.

Catherine: You started a group called Southern Taskforce for Abortion and Reproductive Topics [START], or START for short, shortly after Repeal. Can you talk about how that came about?

Mary: Doctors for Choice became Doctors Together for Yes, rebranded for the Repeal campaign. In the last six weeks before the vote a number of new GPs got involved.

And then we had, this is a funny story, it was a complete happenstance, Two or three weeks after Repeal, we were talking amongst a few of us, saying that we should really try to get together or maybe set up a peer support group for GPs who were interested in providing. One of the GPs offered to send a message out to some people in his contacts, just a basic WhatsApp group. The thought was: the GPs in Doctors for Choice could all invite a few people, and it would grow from there. But in error, it's quite funny in hindsight, he sent the invite link to join the abortion provision group to his entire contact list. He had a huge GP contact list. Anyway, there was uproar with multiple ‘how dare you send me such objectionable material?’ messages. But it was fantastic because we would never have had the audacity to do that if we’d thought about it. The brass neck! And GPs just came out of the woodwork, saying that they would like to join and be supportive.

It was amazing, a complete happenstance, and was one of my personal best times in the years of this often quite isolated business. Within a week, we had 70 or 80 GPs saying, yes, I want to join. Initially, in Doctors for Choice, we were almost unsure of this recruitment. We’d been so careful for so long about confidentiality, we were almost worried, who are these GPs? Who's going to vouch for them? But in the end, we gave it up because it was all fine and such a positive and affirming thing. That's how the abortion support group, START, began. With a bang!

Catherine: How did START grow and evolve at this time?

Mary: Through the autumn, there was phenomenal activity, we subdivided, loads of people came on board. For instance, we had a champion who was absolutely fantastic in terms of actually setting up the peer support groups in START. One GP drove setting up the provider's peer support group, whereas another came into her own in the development of clinical guidance and writing. A group of three of us, wrote the first clinical reference guide – a vital document without which GPs couldn’t be expected to provide a service they had never been educated about. It took many, many nights over about a three-week period to get it across the line. It then had to be sent to the ICGP, and they agreed to it at one of their board meetings in the first week of December 2018. It has since had a second edition with other people making important contributions to it.

Catherine: Can you share more about the mapping exercise you mentioned earlier?

Mary: I think the mapping exercise was probably the most significant thing we in Doctors for Choice had done in advance of Repeal, and that came from the experience of being involved in Global Doctors for Choice. We had the benefit of phenomenal ongoing support, for instance, from Wendy Chavkin and her Columbia University academic department. She came to Ireland and gave us various talks through the last year or two pre-Repeal, largely around conscientious objection and values clarification.

There was significant resistance in the medical community, not in the Department of Health, but everywhere else in the medical community. Largely for two reasons. One, because we were instituting change and they didn't have evidence of this change elsewhere. Two, this whole area of abortion care had always been controlled by obstetrician gynaecologists (OB/GYN), clinical narratives had always been set by OB/GYN professional groups. You could see it in all the campaigning for Repeal; the narratives were always framed and the go-tos were always gynaecologists. The GPs were the secondary line of enquiry. This narrow thinking continues to be an issue. And at the time, GPs didn't see it any other way either, or why would they? They had no way of envisaging this proposed service. So, there was a huge educational piece to be done. Indeed, there were times we even doubted it ourselves. Because it was an absolute uphill struggle, and as fast as we put out one fire trying to answer one set of questions, a new set would be posed and presented as a problem.

Across that summer of 2018, Wendy harnessed PhD students in her department to support us in our need for evidence-based information. We collaborated with the Columbia PhD students to complete literature reviews on topics such as the necessity of provision of ultrasound, and the risk of ectopic pregnancy and death rates from this, provision of the service in the community, the 63 days gestational age limit for medication abortion at the time (it's now gone to 70), the safety of mifepristone and misoprostol. So that's where the PhD students really helped, with synthesizing the literature. It's a credit to them.

Catherine: You have a bank of materials then, I presume Mary, from all of that time.

Mary: Yes, and hundreds upon hundreds of emails with documents and versions of documents. Wendy [Chavkin]'s PhD student Sadie [Bergen] would write up a document with extraordinary detail and references, for instance, on ultrasound. She'd send it to me, and then I would edit it and proof it and rewrite it with Irish English, Irish context, things that were relevant to our service, take out chunks of it, try and keep the referencing straight. Then we would move onto the next topic. She did a lot of work, ultrasound was her main thing, but she also did reviews on mifepristone and misoprostol, gestational terms and limits, etc. As her supervisor, Wendy would read them all. There were many times when I would have spoken to Wendy two, three, and four times a week, and I would have spoken to Sadie sometimes nearly every day.

To be fair to the Department and the HSE, they didn't know in advance what they were trying to implement. They absolutely in the end accepted the bone fides of the evidence base for this proposed service. They went with it, and they were very supportive. There was nothing they wouldn't try to solve. You could argue that it was politically expedient on their part. But I think genuinely, there were some very, very good people in those departments who really tried, and were very committed to making it work.

Catherine: Yeah. And it sounds like it was treated very much as a regular healthcare issue?

Mary: Yes and no. We really promoted that abortion is healthcare, there should be no exceptionalising of the service, and they agreed. But of course, it was exceptionalised, because they gave it such extraordinary time, attention, and financing in the Department and HSE. The exceptionalism suited us, but it was treated differently during that time and in the six months to a year after. They had good attention to detail, a lot of follow up, a lot of feedback, very reactive to suggestions from us as providers.

It was quite the journey in terms of the conceptualising of the service pre-Repeal. I can remember it was at a FIAPAC (International Federation of Abortion and Contraception Professionals) meeting, sitting in one of the presentations about medication abortion and having a light bulb moment. Thinking, is there any reason why we couldn't do that, this could be us. And from that day onwards, trying to put it together as a puzzle, what are all the things that need to be done. And in a way, what really convinced me we could do it were the Internet-based providers; we can adapt their model. A fundamental problem with their model is the ‘othering’ of the service, outside of the regular health service. Abortion health care should just be part of regular care, should be provided by your regular GP. As Internet-based providers had done it already we had sort of unofficial safety data.

Catherine: So, you had then arrived at the point where the legislation got passed at the end of December 2018, and the commitment by the minister was that the service would launch on January the first 2019.

Mary: Yes.

Catherine: What was that like to be the GPs? You were gearing up as a set of GPs to launch this innovative community model of abortion care through general practice in Ireland into the real world. What was that like to prepare, and then to just get out there and do it?

Mary: There were many aspects of the preparation that had to be worked out. For instance, what was going to be the medication, how would GPs access the medication, and would they be writing prescriptions? The Department of Health didn't want that, they felt that you could get into pharmacy objection, and so they went for a central solution where the GPs would choose a pharmacy that would provide it for them and there's a particular order form, and we send the order form to that particular pharmacy, and you order in batches for whatever numbers you predict you’ll need.

The biggest piece we had to do was education of the GPs. We were talking about an entirely new service. The starting position was that there was effectively no abortion education whatsoever at either undergraduate or postgraduate level. The only knowledge most GPs would have had was of patients who might have told them they had gone to England for a surgical abortion. And the only other thing they knew was anything they might have heard us say in the media. Some GPs would have had an awareness of the Internet-based medication abortion services, but they wouldn't have known the names of the medications, for instance. We had an extraordinarily big education piece to do.

Catherine: How did you achieve this monumental education?

Mary: The design of the clinical reference guide was one part of it, but the other part was to have actual in-person training. We got huge support from individuals in the UK, largely, but also elsewhere. I had had quite a lot of interactions with the British Pregnancy Advisory Service (BPAS) over the years, and their CEO, Ann Furedi, had been very supportive of Doctors for Choice. They had come and given us training, we had gone to them, and Patricia Lohr, [BPAS] Medical Director, took a particular interest, and she was really good. Also, [Dr Lohr] recruited a number of very good people to come and assist us.

We ran a training day in Dublin for 25 GPs, on the 15 December 2018. We had security arranged and we couldn't publicise the venue until the morning of the meeting because of the fear of protests. But this will tell you how the service was considered to be a big deal, Simon Harris, the Minister for Health, came to the meeting, just walked in with all his entourage, shook everybody's hand. He wanted to be there even though we agreed there was no photographs and no publicity around the event, because it was all delicate. He came to show support.

After that, we ran a number of education meetings. There was absolutely phenomenal stepping up by the early START group, which at the time were largely Cork based, but some key Dublin-based people and then people came on board from other places, over the first sort of 6 months.

Catherine: You had a bank of international committed providers or facilitators, and trainers, and people who made it happen, so that was obviously really important?

Mary: Really important, and that's where the value of Global Doctors for Choice came in. We had this huge bank of support in the UK, but, for instance, Wendy Norman in Canada, who was very helpful, she facilitated by providing educational updates. There was extraordinary collegiality.

Catherine: And you could see a model of training?

Mary: Yes, I could see how other people did it, and what needed to be done. We tweaked the training all the time, translated it into the Irish context. Within six months of starting, we had updated it. None of this was perfect. There were so many compromises, but in the end, we decided to roll with as many of them as we could. For instance, three of us wrote the clinical reference guide, we broke our hearts with it, we sweated to get it done.

As a supplement to the guide, a piece on conscientious objection (which GPs are entitled to do) was developed. It outlined the minimum you should do, know, and say as a conscientious objector. [Another GP colleague] and I wrote it as an appendix, to go in the back of the training booklet. We were kind of proud of it, I thought it was nicely written. But what did the ICGP go and do without our knowledge or consent? They took it out of the appendix and made it the first chapter. We were really annoyed; a training document for abortion providers now has the first chapter on conscientious objection. In the second edition, it is an appendix.

Catherine: You have primed everything, this international mobilisation of enormous resources, people, materials, and knowledge. And now January the 1st ticked over and…?

Mary: We nearly died of fright.

Catherine: What was that like?

Mary: We were a bit concerned about the first week because we had predicted there would be a surge because of pent-up demand – people who might have otherwise gone to England or used the Internet services. And then there's always Christmas surges. But it all went well, and I think we had 90 or a hundred providers in the first week, and it was enough.

Catherine: Geographically clustered or dispersed, or how?

Mary: Geographically, five or six counties didn’t have a provider out of twenty-six counties. Those without a provider were largely the Northwest and Wexford. In Cork, we were falling over each other there were so many of us.

Catherine: Did START have the WhatsApp Peer Support group at that point? Were you in some kind of communication with each other when providing?

Mary: We had the WhatsApp group at that point, and it was busy because people understandably had so many questions. We took the policy that no question is too simple. The group is for learning and support; we encourage questions even if they have been asked before. There are many people on the chat who answer questions, and it works well.

Catherine: Doctors for Choice had evolved into START, which was conceptualised as a peer training and support entity. The distinction between Doctors for Choice and START was about peer training and support, is that it?

Mary: Yes, they merged into one another. The leadership of Doctors for Choice, the GP part of it, merged into START. But then START developed its whole organic membership of people who hadn't been in Doctors for Choice. So now, effectively, Doctors for Choice is quiet – from an advocacy point of view, there's little to be doing. We keep the brand going at the moment but START is where the work is at.

Catherine: START used the technology of WhatsApp from the outset. The clinical guidance the WhatsApp group provided was its main function?

Mary: START's big achievement was the formal clinical guidance. Even though the guidance was entirely branded by the ICGP, and still is, it's START's document.

Catherine: Did the ICGP in any way formally relate to START?

Mary: Yes, in the sense that it would have had meetings with START. The first educational training day that START had in Dublin, the ICGP facilitated it. The ICGP knew they had to train their GPs. Now, START does considerably more training than the college does, we think the college never does enough. However, the college has taken on the fact that it bears a responsibility to train people in abortion provision. In the same way, it trains people in contraception provision. It was a somewhat uneasy relationship. Some of the senior people in the ICGP are fairly anti-choice, but more so many of them are very, very cautious in this area.

Catherine: Would you see within the ICGP anything parallel to how ICGP relates to START?

Mary: The ICGP relates to many subgroups or special interest groups, for example, a special interest group in nursing homes, in diabetes, in minor surgery, in dermatology.

But it doesn't have a touchy relationship with those. I’ll put it like this, you always get the impression in college that they think that somehow the pro-abortion leaders will sprout two heads. They don't think about the dermatology GPs that way.

Catherine: The capacity of anything to do with the reproductive body to unsettle?

Mary: Yeah, that us in reproductive health are just unstable and fundamentally unreliable. There was an irony in me going from this position to becoming ICGP President and COVID coming along. I ended up the college figurehead in the media and on the National Emergency Team.

Catherine: START was two parts: first, an organic peer support group and second, a trainer in abortion care best practice. But as time went on people were independently providing abortion services. What still needed attention from the implementation phase? Was START going to continue?

Mary: We had several different strands that needed attention. One was the well-publicised strand of uneven geographic distribution of abortion providers and trying to improve the numbers. We took a grassroots approach of going into those areas and working with GPs so they could understand the service in their local context. However, this has only happened in Mayo, and very recently. But we also knew that new providers needed quite a lot of support in getting started. Some GPs have become quite autonomous and realised that this isn't a complicated service, you know, you need some training in it, but it's not hugely complicated. But many GP providers still feel different or slightly closeted, so there's a huge collegiality in the WhatsApp support.

Catherine: Yeah, but those strategic things Mary in terms of, you know, being alert to what makes for a better service, an accessible service, a quality service for women, like geographical distribution or ongoing training, is that something that START is doing organically or is there any other mechanism that START has been relating to?

Mary: Yes, the Clinical Advisory Forum through the National Women's and Infants Health Program (NWIHP) in the HSE. The Forum was originally established as a working group, then it morphed into a clinical governance group. I was invited onto it through my role as ICGP Vice President. START initially had its own representative.

Catherine: The NWIHP became the designated unit that would look after abortion care?

Mary: Yes, from the very beginning, they coordinated all the strands making the service happen: from medication licensing, pharmacy, and MyOptions. All of that works out of that department. Dr Cliona Murphy is the clinical lead of NWIHP and Dr Aoife Mullally is the clinical lead for abortion provision and reports to Cliona. Both of them are Obstetricians.

Catherine: Is the way in which START features on the Clinical Advisory Forum formalised?

Mary: START doesn’t actually have a designated seat. The HSE and ICGP Women's Health lead does sit on it, as do others from the HSE and obstetrics, but there is not actually a representative from among GPs providing abortion care. This has become apparent with the reconfiguration of the forum after the Review. Now, neither the ICGP or START were invited to attend and changes can no longer be cross checked with START. As a result, there is no liaison directly with General Practice providers. The ICGP Women's Health Lead is a providing GP and is great but is not there wearing the GP provider's hat.

START wrote a letter in January 2024 flagging problems in the service that are evident in the general practice service as detailed through START: the lack of structured education and training, the lack of outreach into remote areas, the lack of any data collection. We listed about nine problems. But the key solution to them all is to have a clinical lead inPprimary Care who would focus on the general practice provision, which forms about 90% of the service. We didn't get one single reply, not even an acknowledgement from NWIHP or anybody, that they received our letter.

Catherine: Okay. And that's where we are now. The HSE are looking towards the ICGP as their GP representative and START are being kind of looked past?

Mary: Yes. I think that is for two reasons. One, they know GPs in START are dogged in their pursuit of a quality service for women. Secondly, we are outside the circle of the HSE, Department of Health who all know and understand each other and know no one is going to rock the boat or call them out.

Catherine: Does START have a formal relationship with the ICGP?

Mary: No, a special interest group designation has never been formalised, there's no ongoing meetings with the ICGP, they're all informal in terms of briefings. The Women's Health Lead of the ICGP is our nearest contact and is very helpful. We don’t have an equivalent in the HSE.

Catherine: What was initially an incredibly, instrumentally important relationship has evolved into a distant one. That pre-existing, very close working relationship is being disregarded?

Mary: I think in reality they just don't need us anymore. The service is largely successful and up and running. The Clinical Advisory Forum does pay attention to the public statements of START in terms of what we think should be done better or differently. They know what we're looking for without ever having to meet us or give us any potential say or decision-making power, and it means they can control the meeting outcomes and not take criticism for not doing anything. And that is not unusual, health departments and organisations like that want to keep a distance from advocacy groups, you can see it in disability rights. There is not an understanding of general practice and how autonomous we are.

Catherine: What are the long-standing relationship dynamics between the Consultant Obstetrician/Gynaecologist providers and General Practitioners?

Mary: There is some territorialism. Some of it is historic, Obstetricians don't understand what GPs do. We're independent providers who don’t have line managers. And once we don't cause trouble on their doorsteps, they're not really that interested either. They are not interested in evaluating or researching the service. Once any proposed research doesn’t provide more information about the hospital service, they weren't interested.

Catherine: Is it related to power relations between hospitals and primary care GPs?

Mary: Yes.

Catherine: How are referral pathways into hospitals negotiated locally between each GP and their local hospital? Is there any infrastructure for that?

Mary: There's no national infrastructure, and we want there to be. The pathways should be documented. There's a lot of resistance to documenting pathways, because then obstetricians are afraid we might use them and that it'll increase their workload. That's historic from other issues around GPs. Thus, GPs work it out locally and, to be fair, the midwife coordinators are generally very good and go above and beyond. Several of them are in START. There's a lot of very reactive sharing and learning. For example, if somebody puts into the WhatsApp group, ‘any idea who the Midwife Coordinator is in a specific hospital, the number I have, it's not answering.’ Within minutes somebody will be in, ‘oh their name's x, and this is the number I have.’

Catherine: The coordinating midwife has become the de facto link between GPs and hospital care?

Mary: Yes. In Cork, for instance, there are three coordinating midwives because they job share. They're very good. I no longer really know which Obstetrician does what clinic on what day, I don't need to know. It's the midwife coordinators we talk to for signposting and arranging of a hospital service if a patient needs it.

Catherine: Given the particular kind of role that the Review was given and the designation it was given within the Department of Health and the HSE, how do you feel the review related to GP providers?

Mary: I think the review related to GP providers well. And I think that was a credit to the leadership of the Review and the way the Review was coordinated. I think GPs felt heard, many of us were interviewed, people gave a lot of time to it, and that was well reported. Yes, so I think the independent chair of the Review, Marie O'Shea, did useful things like attend the START Conference in October of 2022 and interviewed START leadership. She did a wide consultation from a GP point of view.

I think she appropriately tried to identify where the problems in the service lie. There wasn't necessarily enough weight given to the proportion of the service provided by GPs, but I wouldn't get too bothered about it, it was fine.

Catherine: We’ve discussed issues that are outstanding, such as clinical governance, issues with hospital referral pathways, the way the service has evolved, and the way START has been related to. Do you think the Review has captured that?

Mary: I don’t think the Review captured that. The relationship between START and say the HSE or the Department of Health is a vital one and needs to be nurtured and should be formalised. The Department took START's involvement through the early years entirely for granted. And they can’t presume they will continue to have innovation and progress in the service if they neglect that. But then, by nature, the individuals in START are all hugely motivated, and they want to improve the service and innovate it. So, I and [other likeminded colleagues], won't be put off just because they won't listen, we'll do it anyway. We’ve been trying to develop a data collection system for researching the service, and we have not been able to get it through the HSE. We’ve now found a workaround with the academic centres ² . This is an example of what's needed.

Catherine: To summarize, this is a situation where START were very much at the centre of this innovation and have since been moved to the edges. Because of the particular vantage point and the commitment that START members have to a knowledge base of quality abortion care, there are lots of strategic ways that START needs to be involved, with seats at the table, and your sense is that they are being kind of pushed out?

Mary: Yes. The average START member sees the primary function of START as supporting them, it's a peer support providers group. And START continues to provide that well. Those of us who are in committee sections of START see that we have a bigger role. Historically, we had a large role in making the service happen and in its success. We see that we have an ongoing role in terms of monitoring and pointing out problems in the service and trying to improve them.

But yes, if your perspective is that of central HSE you’d say START has been sidelined. But if you're in START, you wouldn't say it's been sidelined at all. It's still as central and important to many of us providing abortion care as it ever was. And I think the women and patients, if asked, would think START is central to ensuring a quality service for them.

Catherine: Thank you Dr Mary Favier.