Dr. Brendan O'Shea:

We will move on to the management of crisis pregnancy as experienced, in particular, by members of the college and general practitioners nationally. To help outline the typical crisis pregnancy scenario, we outline in our submission a typical anonymised vignette. Sandra is 38 years of age and presents to her GP. She has three children, but separated from her husband three weeks ago as he had become increasingly abusive towards her and her children. The GP has become increasingly concerned about Sandra's isolation and lack of supports. Sandra comes to see her GP and states that she missed her period two weeks ago. She thinks she may be pregnant but she has not done a pregnancy test herself. She looks concerned and is anxious. Before the GP performs a pregnancy test, she explores Sandra's feelings and asks if she would be happy if she found out that she was pregnant.

Sandra bursts into tears. The general practitioner, GP, listens to her many concerns and explains that no matter what happens, the practice will be there to support Sandra in the consultation and beyond. The GP proceeds to check a urine sample and it confirms she is pregnant. Sandra looks despondent and says she does not want to be pregnant.

Every crisis pregnancy is different. Reasons a pregnancy is unwanted are personal and unique to each individual, circumstances and the person's family. However, the approach taken by the doctor to managing crisis pregnancy is the same. Firstly, the pregnancy is confirmed. As the vignette outlines, the GP cannot assume all pregnancies are always wanted. GPs are well placed to sensitively inquire about the woman's feelings and confirm the pregnancy.

Second, we proceed to non-directive counselling and discussion of options. The next step in management is to support the woman to reach the best decision for her, providing a safe reflective space for her to do so. The main goals involved include maintaining trust, helping the woman formulate a clear definition of the problems and establishing the goals of management so that the crisis can be resolved. This involves non-directive, non-judgmental, compassionate, empathetic listening, sometimes over two or more consultations over the course of weeks. There is a legal obligation on those providing pregnancy counselling in Ireland, including general practitioners, to discuss all options in a non-directive manner where a woman wants information on abortion.

Third, there are three options available to the woman, continuing with the pregnancy, abortion and adoption, although the latter is relatively rarely chosen. A doctor has an ethical obligation not to allow his or her personal moral standards to influence treatment of patients. Where the doctor has a conscientious objection to a course of action, he or she must explain this to the patient and provide the names of other doctors available to the patient in a timely manner. Effective communication in a crisis situation demands time, considerable patience and careful thought. The GP must enable the woman to reach an informed decision, to minimise emotional disturbance, whatever decision is made, and to lessen the risk of further unwanted pregnancy.

In general practice, we hope and believe that women find space, are listened to, and can share, explore and address their concerns in a familiar setting with a physician who is very familiar to them in most cases. Supporting this personalised care is a core value of the Irish College of General Practitioners, ICGP, so that these consultations, and indeed any other consultations involving the woman and the process of decision making, are all undertaken in a non-directional and supportive process. The role of the GP and practice nurse is chiefly concerned with the provision of support, information, and clear commitment to follow-up care in the practice. Sometimes specialist counselling is required. For example, if a woman is younger, has poorer support structures or has an active, significant mental illness, she may benefit from specialist counselling services. In this case, Irish GPs may recommend a specialist, accredited, counselling service, which offers accurate information. These services are funded by the HSE sexual health and crisis pregnancy programme, and locations and descriptions can be found on www.positiveoptions.ie.

If a woman chooses to continue her pregnancy, the GP will continue to provide compassionate antenatal care to the woman, ensuring adequate supports are present and addressing the important issue of postpartum contraception.

In the clinical vignette we have described, Sandra chooses to travel to the UK for an abortion. GPs cannot actually refer to or make an appointment at a clinic in the UK on behalf of a woman who chooses an abortion. We may provide a copy of the patient's medical records to the patient. GPs would also encourage women to return to the practice after having an abortion if they have any concerns. GPs would also discuss post-abortion contraception. Irish GPs may need to consider a dating ultrasound if the dates of the pregnancy are uncertain. Any GP who has a conscientious objection must refer the woman in a timely manner to another colleague. Abortion is a relatively very safe medical procedure. The ICGP understands that an increasing proportion of women will purchase online hormonal abortifacient medications. In these instances, it may or may not become known to their GP in subsequent consultations. There is clearly increased use of illegal abortifacients, both from anecdotal evidence from GPs and objective measures such as customs seizures, and a recent paper which suggests that more than 5,000 women requested abortion pills in this way between January 2010 and December 2015. The trend is increasing significantly and rapidly.