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The first survey of attitudes of medical students in Ireland towards termination of pregnancy
  1. James M Fitzgerald,
  2. Katherine E Krause,
  3. Darya Yermak,
  4. Suzanne Dunne,
  5. Ailish Hannigan,
  6. Walter Cullen,
  7. David Meagher,
  8. Deirdre McGrath,
  9. Paul Finucane,
  10. Calvin Coffey,
  11. Colum Dunne
  1. Graduate Entry Medical School, University of Limerick, Limerick, Ireland
  1. Correspondence to Professor Colum Dunne, Graduate Entry Medical School, University of Limerick, Limerick, Ireland; colum.dunne{at}ul.ie

Abstract

Background Since the UK Abortion Act (1967), women have travelled from Ireland to the UK for legal abortion. In 2011 >4000 women did so. Knowledge and attitudes of medical students towards abortion have been published, however, this is the first such report from Ireland.

Objective To investigate medical students’ attitudes towards abortion in Ireland.

Methods All medical students at the University of Limerick, and physicians who graduated from the university within the previous 12 months, were invited via email to complete an anonymous online survey. The questionnaire comprised 17 questions. Quantitative and qualitative analyses were performed.

Results Response rate was 45% (n=169; 55% women; 88.2% <30 years of age; 66.7% Irish; 29.2% North American). Outcomes were: abortion should not be legally available (7.1%), abortion should be allowed in limited circumstances only (35.5%), abortion should be legally available upon request (55%). 72.8% of respondents were moderately/strongly prochoice (74% of women/71% of men/72% and 76% of Irish and North American respondents, respectively). Students aged >30 years were less likely to be prochoice (55%). While 95.2% believed that education on abortion should be offered within medical school curricula, 28.8% stated that they would decline to terminate pregnancies even if legally permitted. While 58.8% indicated that they might perform legal abortions once qualified, 25.7% would do so under limited circumstances only.

Conclusions The majority of participants wanted education regarding abortion. Despite being predominantly prochoice, considerably fewer students, irrespective of nationality, indicated that they would perform abortions.

  • Abortion
  • Applied and Professional Ethics
  • Clinical Ethics
  • Embryos and Fetuses
  • Obstetrics and Gynaecology

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Introduction

Abortion evokes strong opinion in society in general and, in the context of elective termination of pregnancy (TOP) being illegal there since 1861, is especially contentious in Ireland. As a result of more liberal abortion policies in other European countries1 including the UK (UK Abortion Act 1967), considerable numbers of women normally resident in Ireland have had their pregnancies terminated in the UK2 with more than 4000 such abortions performed in Britain during 2010 and 2011.3 ,4 These numbers correspond to approximately 5% of births recorded during the same period in Ireland.5 Data relating to Irish women accessing TOP services in other European countries are not available.

Surveys of knowledge and attitudes of medical and nursing students towards TOP have been performed mainly in the USA,6–9 South America,10 ,11 South Africa,12 ,13 the Middle East14 and Europe.15–17 These studies described considerable variation in attitudes that is reflective of individual personal beliefs, legal environments and educational experiences. In cases where students expressed desire for additional abortion-related education material in their curriculum, or for more permissive laws regarding TOP, this did not necessarily correlate with a willingness to participate in abortions.9 ,15 Gleeson et al (2008) surveyed UK medical students’ attitudes towards TOP7 reporting that while 62% of the 300 students surveyed were prochoice, overall beliefs towards the status of the foetus and rights of women correlated with UK law, but was dependent on level of participation that would be required of the student and their religious background.

Arguably, Steele's 2009 study of medical students in northern Ireland18 is culturally most relevant to medical education in Ireland, particularly as the UK Abortion Act 1967 does not extend to northern Ireland where, as a consequence, more restrictive grounds for TOP prevail. In that study, the majority of the 86 participants believed that their curriculum had inadequately covered the topic of TOP, but only14.3% of the students declared themselves to be proabortion. No such studies have been conducted in Ireland. Therefore, this paper presents the first report of attitudes of medical students and intern year graduates (first year post-conferring and analogous to UK Foundation Year 1) in Ireland towards TOP.

Methods

Participants

Medical students and intern year graduates (n=373) of the University of Limerick were contacted by email in July and August 2012 and were provided a link to the Survey Monkey online study instrument and to a concise, unbiased explanation of the survey topic. Participation was voluntary and anonymous. The first question of the survey asked students to confirm that they consented to their responses being used in this study. Conduction of the study and its design, taking into consideration published surveys on attitudes to TOP,16 ,18 were approved by the ethics committee of the Faculty of Education and Health Sciences, University of Limerick, Ireland.

Data collection and analysis

The survey questions were designed to elicit participants’ views on TOP, in varying circumstances. The questionnaire comprised two sections: the first section collected demographic data of each participant (age, gender, nationality, marital status, biological children, year of medical school or intern), while the second section explored attitudes towards TOP, particularly in Ireland. Specific questions related to: intended medical specialty; whether strongly or moderately prolife or prochoice, undecided or neutral; provision of education on abortion; legal status of abortion in Ireland; their reasoning as to why abortion should be legalised, if supportive; situations under which abortions should be allowed if available only under limited circumstances; willingness to perform abortions if legally allowed to do so; and reasons why they would decline to perform such procedures. The survey was piloted before use. The data were downloaded from Survey Monkey software to an electronic data file and quantitative analysis was performed using Statistical Packages for the Social Sciences (V.20.0). A Z-test for proportions (two-sided at 5% level of significance) was performed to investigate significant differences in attitudes by gender and nationality (Irish, North American). An opportunity for additional free text comments was provided in the study. This section was undirected, and comments could be added at the participants’ discretion. These comments were analysed using NVivo (V.9).

Results

Demographics

The overall response rate was 45% (n=169; 55% women; 88.2% <30 years of age; 66.7% Irish; 29.2% North American) (table 1). Totally, 84% of the students were single (no divorcees), 8.3% married and 7.7% in domestic partnerships; 5.3% of the participants had biological children. Responses were reasonably well dispersed across all 4 years of the medical programme and from the postgraduation intern year: 26.6% of responses were from year 1; 18.9% from year 2; 21.9% from year 3; 20.1% from year 4; and 12.4% from the intern year. Intended fields of medical specialisation indicated by participants were as follows: unsure (26.2%); general practitioner (GP) (20.8%); internal medicine—all disciplines (16.7%); surgery—all disciplines (10.1%); paediatrics (7.7%); psychiatry (4.2%); obstetrics and gynaecology (4.2%) and other (10.1%).

Table 1

Medical student demographics and stance on abortion

Attitudes to abortion

In the context of 72.8% of respondents being moderately/strongly prochoice (74% women/71% men/72% Irish/76% North American), responses received were as follows: abortion should not be legally available (7.1%); abortion should be allowed in limited circumstances only (35.5%); TOP should be legally available upon request (55%); unsure 2.4% (table 2). Where students indicated that they believed that TOP should be legal in Ireland, the most common reasons selected (of those provided) were that ‘the woman has the right to terminate or not terminate a pregnancy’ (76.2%), and ‘laws against abortion don't stop abortion, they simply make it less safe’ (68.9%). Other choices selected were: ‘the foetus is not yet a person’ (22.1%); ‘the foetus is not yet sentient’ (14.8%); ‘it should be a purely medical decision’ (17.2%); and ‘other’ (9.8%) (table 2). Where students indicated that they believed that abortion should not be legal in Ireland, the most frequently chosen reason was that ‘the foetus is a person’ (78.9%) (table 2). Religion was cited least frequently (21.1%). When asked whether education on TOP should be offered as part of the medical curriculum, a significant majority believed that it should be mandatory (76.3%); 18.9% preferred that such education should be optional, with 3.0% supporting non-provision of such information.

Table 2

Attitudes towards abortion and rationale*

Influence of students’ nationality, gender and age

The majority of North American students were in favour of TOP being legally available on request (69% vs 49% Irish; 95% CI for difference 4% to 36%, p=0.02) while Irish students largely favoured abortion being legalised only under certain circumstances (43% vs 20% North American; 95% CI for difference 5% to 36%, p=0.006). In terms of gender, females irrespective of nationality tended to be more supportive of TOP being available on request than their male colleagues (58% women vs 51% men; p=0.36), although this difference was not statistically significant. Paradoxically, however, female students indicated greater reticence towards actually performing abortions if legalised (32% women vs 24% men; p=0.25); again this difference was not statistically significant. It is notable that older students (>30 years) and North American students declared themselves more willing than younger or Irish students to perform abortions if legally permitted to do so.

Attitudes towards abortion performed under limited circumstances

While 58.8% of the survey participants indicated that they might perform legal abortions once qualified, 25.7% stated that they would do so under limited circumstances only (table 3). Specifically, the majority of students expressing this opinion were of the view that eligible circumstances would include ‘where the foetus has severe abnormalities and is unlikely to survive’, ‘where pregnancy is of great risk to the life of the mother’, ‘where the pregnancy is the result of rape’ or ‘…result of incest’. However, considerably fewer students believed that psychological distress of the mother or poverty were eligible arguments for TOP (table 3).

Table 3

Performance of abortion and circumstances where appropriate

Students’ comments regarding abortion

No direction was provided to participants regarding completion of the comments section of the survey; 33 respondents provided comments, a significant proportion of whom (16/33) expressed a prochoice opinion. Notably, however, in some of these cases, responders further stated that they did not agree with TOP at a personal level. The importance of the timing of TOP was also referred to with comments stating that participants would prefer, if TOP were legal, to perform chemical and early term abortions (up to 8–10 weeks). Later-term abortions, which are allowed in some jurisdictions, were commented on negatively. Some respondents stated that they would be willing to perform TOP in the case of a medical emergency only (ie, when the life of the woman was in danger) and that they believed that provision of such a service should be protected from abuse.

On the theme of medical information, opinions were expressed that education on all aspects of abortion provision is important—not necessarily limited to those medical professionals who may perform TOP—to allow for full care of, and to enable accurate information be provided to, patients. On a related theme, a number of participants were satisfied to provide information on availability of abortions outside of the Irish State, while expressing an opinion that Ireland should remain abortion-free.

Several respondents expressed views that have been explored by other researchers, such as the involvement of religion in the debate on TOP, and that while some physicians may object to performing abortions based on their own beliefs, this should not impact on them providing professional and fully inclusive care to patients.19 Similarly, that fathers should have an input into the decision as to whether the mother should terminate a pregnancy.20 Other comments were that: abortion should not be permitted in the case where the woman expresses suicidal feelings—as this could be used as a ruse for obtaining an abortion; the Irish State should not bear the cost of abortion, and a preference for performing TOP only where preabortion counselling had been provided.

Discussion

This is the first study to investigate the attitudes of medical students towards TOP and abortion legislation in Ireland. In summary, the majority of medical students in this cohort were moderately/strongly prochoice, and stated beliefs that were generally congruent with their peers internationally, for example, the UK, Norway, South Africa and Malaysia.8 ,13 ,18 ,21 However, it should be noted that cultural differences between Irish and North American students were apparent in this study, whereby medical students from North America were largely in favour of TOP being legally available on request, while Irish students (although similarly identified as predominantly moderately/strongly prochoice) expressed less support for TOP on request and to a greater extent favoured TOP under certain circumstances only. It is reasonable to speculate that the opinions expressed by Irish participants in this study may be representative, in general, of their peers (ie, age, gender, third-level education) within the Irish population, and reflect a relatively conservative cultural, political and religious environment vis-à-vis beliefs, education and practices. Indeed, in 2012, Murphy et al reported a questionnaire-based survey of attitudes and clinical experiences of Irish GPs and GPs-in-training (n=218), reporting that 10% of respondents believed that abortion should never be allowed, 25% believed that abortion should be allowed in limited circumstances and 51% supporting the position that abortion should be available to all women on request.22 Overall results in our study were generally similar to those seen in the GP paper, albeit that the medical student cohort favoured availability of TOP in limited circumstances to a greater extent, possibly due to a relatively idealistic and inexperienced perspective on medical practice. It is noteworthy that when the inclusion of North American students was corrected for, the greatest disparity between practicing Irish GPs and Irish medical students was their opinions regarding TOP in limited circumstances (25% GPs vs 43% students). In line with previously reported observations in the UK,16 practicing GPs appeared more supportive of abortion on request than Irish students, 51% versus 49%, respectively. However, this relationship is reversed when the attitudes of North American students are included. The relevance of the Irish GP study to our survey is detracted from, to an extent, as only 20.8% of the medical students predicted that they would become GPs. However, it is the only other Irish study on this topic on which to make comparisons.

Conclusions

This is the first survey of medical students in Ireland regarding attitudes towards TOP and, at a time when TOP in Ireland and availability of safe abortion provision to Irish women (in Ireland or elsewhere) is being clinically examined in the Irish parliament, is timely and relevant. It is important to note that the participating students are unlikely to have seen abortions performed as part of their medical education, with the possible exception of the North American students via non-Irish elective modules. The study did not investigate students’ existing knowledge of TOP methods although it is clear, as with other studies of this type, that education on abortion would be preferred by the majority of the participants. Response to the survey was voluntary and students with stronger views may have been more likely to respond. However, the demographics of those who responded are broadly similar to the population of students in the school. This study is also predominantly quantitative, and may not reflect nuances that may be determined using a more qualitative approach. It would be insightful to more fully understand attitudes of both graduate entry and direct entry medical students in Ireland to the varying level of participation in the abortion process that they may feel comfortable participating in (eg, referral to a specialist, writing of abortion-related prescriptions, active involvement in obstetric and gynaecological procedures, etc), to determine the potential for conscientious objection, and to explore analogous nurse, midwife and allied professional attitudes towards TOP in Ireland.

References

Footnotes

  • Contributors Each author contributed to: conception and design, acquisition of data or analysis and interpretation of data, and drafting the article or revising it critically for important intellectual content, and final approval of the version published.

  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the Ethics Committee of the Faculty of Education and Health Sciences, University of Limerick, Ireland.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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