Restrictive points of entry into abortion care in Ireland: a qualitative study of expectations and experiences with the service.

This article focuses on access to early medical abortion care under Section 12 of the Health (Regulation of Termination of Pregnancy) Act 2018, in Ireland and identifies existing barriers resulting from gaps in current policy design. The article draws primarily on qualitative interviews with 24 service users, 20 primary healthcare providers in the community and 27 key informants, including from grassroots groups that work with women from different migrant communities, to examine service users' experiences accessing early medical abortions on request up to 12 weeks gestation. The interviews were part of a wider mixed-methods study from 2020-2021 examining the barriers and facilitators to the implementation of abortion policy in Ireland. Our findings highlight care seekers' experiences with the GP-led service provision, including delays, facing non-providers, the mandatory three-day waiting period, and oversubscribed women's health and family planning clinics. Our findings also highlight the compounding challenges for migrants and additional barriers posed by the geographical distribution of the service and the 12-week gestational limit. Finally, it focuses on the remaining challenges for racialised and other marginalised groups. In order to provide a "thick description" of women's lives and the complexity of their experiences with abortion services in Ireland, we also present two narrative vignettes of service users, and their experiences with delays and navigating the healthcare system as migrants. To this effect, this article applies a reproductive justice framework to the results to highlight the compounding effects of these barriers on people located along multiple axes of social inequality.

Abortion policy implementation in Ireland: successes and challenges in the establishment of hospital-based services.

Objective: To describe successes and highlight remaining challenges in the establishment of hospital-based abortion services after legal change in the Republic of Ireland. Methods: We conducted a mixed-methods study on the implementation of abortion policy in Ireland. In this manuscript, we present the results from a qualitative analysis of in-depth interviews conducted with hospital-based providers, service users, and key informants. We used Dedoose software to conduct a thematic analysis of the data. Results: We report findings from interviews with 28 obstetrician gynecologists, midwives, psychiatrists, anesthesiologists, and nurses; a subset of 7 service users who sought care in hospitals; and 27 key informants. In this analysis, we describe how key themes that pertain to information, capacity and power, facilitated and hindered the implementation of hospital-based abortion services. We found that individual champions are key to establishing the service, but their motivation is not always sufficient to integrate abortion into existing clinical services, and conscientious objection is a persistent barrier to expanding abortion services. The main challenges highlighted here are lack of abortion provision at some hospitals and limited access to surgical abortion at most hospitals due to provider-level, logistical, and infrastructure barriers. Conclusions: This study presents new information on how abortion policy is implemented on the ground in hospital settings. Its findings can inform public health officials and providers in Ireland and other countries wishing to establish abortion services.

Information flow as reproductive governance. Patient journey analysis of information barriers and facilitators to abortion care in the republic of Ireland.

Background: Information flow - information communication and transmission pathways and practices within healthcare systems - impacts patient journeys. Historically, regulating information flow was a key technology of reproductive governance in the Republic of Ireland. Pre-2018, law and the State sustained informational barriers to and through abortion care in Ireland. An expanded abortion service was implemented in January 2019. Method: Patient Journey Analysis (PJA) interrogates informational facilitators and barriers to/through post-2019 abortion care in Ireland. We focus on information flow at the interfaces between the 'public' sphere and 'point of entry', 'point of entry' and primary care, and primary and secondary care. Materials: The paper uses data from a mixed-method study. A tool for assessing online abortion service information (ASIAT), desktop research, and qualitative data from 108 in-depth interviews with providers, policy-makers, advocacy groups, and service users informed the analysis. Results: Abortion patient journeys vary. Information flow issues, e.g. communication of how to access services, referral systems, and information handover, act as barriers and facilitators. Barriers increase where movement from primary to secondary is needed. Applications: The article identifies good practice in information flow strategy, as well as areas for development. It illustrates the significance of information flow in accomplishing reproductive governance.

Abortion policy implementation in Ireland: Lessons from the community model of care.

BACKGROUND: In 2018, the right to lawful abortion in the Republic of Ireland significantly expanded, and service provision commenced on 1 January, 2019. Community provision of early medical abortion to 9 weeks plus 6 days gestation delivered by General Practitioners constitutes the backbone of the Irish abortion policy implementation. We conducted a study in 2020-2021 to examine the barriers and facilitators of the Irish abortion policy implementation. METHODS: We collected data using qualitative in-depth interviews (IDIs) which were conducted in-person or remotely. We coded and analysed interview transcripts following the grounded theory approach. RESULTS: We collected 108 IDIs in Ireland from May 2020 to March 2021. This article draws on 79 IDIs with three participant samples directly relevant to the community model of care: (a) 27 key informants involved in the abortion policy development and implementation representing government healthcare administration, medical professionals, and advocacy organisations, (b) 22 healthcare providers involved in abortion provision in community settings, and (c) 30 service users who sought abortion services in 2020. Facilitators of community-based abortion provision have been: a collaborative approach between the Irish government and the medical community to develop the model of care, and strong support systems for providers. The MyOptions helpline for service users is a successful national referral model. The main barriers to provision are the mandatory 3-day wait, unclear or slow referral pathways from primary to hospital care, barriers for migrants, and a shortage and incomplete geographic distribution of providers, especially in rural areas. CONCLUSIONS: We conclude that access to abortion care in Ireland has been greatly expanded since the policy implementation in 2019. The community delivery of care and the national helpline constitute key features of the Irish abortion policy implementation that could be duplicated in other contexts and countries. Several challenges to full abortion policy implementation remain.

Analysing MyOptions: experiences of Ireland's abortion information and support service.

BACKGROUND: In 2018, the Irish government enacted a liberalised abortion law permitting expanded access to abortion from January 2019. A dedicated information and support service - MyOptions - was established to provide non-directive counselling and clinical advice about unplanned pregnancy. MyOptions provides contact details for abortion providers but does not make appointments for abortion-seekers. In 2020, the Abortion Rights Campaign (ARC) conducted research into Irish residents' experiences of abortion care under the new law, including their experiences with MyOptions. METHODS: Between September 2020 and March 2021, ARC administered an online survey. Qualitative data were coded using NVIVO software and analysed through thematic analysis. Quantitative data were analysed descriptively. This article analyses a subsection of these data to answer the question: What were abortion-seekers' experiences of using MyOptions? RESULTS: Many respondents were unaware of MyOptions before becoming pregnant. Some described MyOptions as useful and compassionate. Others noted a lack of clarity from MyOptions about the scope of its service and a lack of information on accessing abortion after 12 weeks. Respondents reported frustration that the service did not arrange appointments, explaining that having to contact general practitioners (GPs) themselves was stressful and time-consuming, as was GPs' refusal to provide care or refer to a willing provider. CONCLUSIONS: MyOptions primarily benefits abortion-seekers whose pregnancies are under 12 weeks and who are comfortable contacting a GP themselves. The addition of an appointments booking service and guidance on how to access abortion for medical reasons and abortion after 12 weeks could improve the service.

Laboratory tests in patients treated with isotretinoin: occurrence of liver and muscle abnormalities and failure of AST and ALT to predict liver abnormality.

Current laboratory monitoring may not be optimal. A retrospective chart review was performed on thelaboratory results of 246 patients who were treated with isotretinoin for acne over a 9-year period. Tests obtained were CBC, lipid panel, AST, ALT, CK, GGT,and C-reactive protein. Thirty-five patients had an elevated AST and 35 of these had an elevated CK; 32 had an elevated ALT and 11 of these had an elevated CK. Thirteen patients had an elevated GGT; in 5 this was the only abnormality, whereas 8 had a GGT elevation accompanied by an elevated AST or ALT. Two had an elevated GGT and an elevated CK with normal AST and ALT. Fifty-two patients had a single episode of elevated CK, of which 22 were female. However, 57 had multiple CK elevations and only one was female. Thirty-five patients had CK elevations <2 times normal; 38 had levels between 2 and 3 times normal, 18 had levels between 3 and 4 times normal, and 18 had levels greater than 4 times normal. We suggest that ALT and AST are not useful for monitoring isotretinoin therapy and that GGT and CK may be of greater value in managing patients.