Creating an Enabling Environment for Community-Based Abortion Care: A Mixed Method Systematic Review from Ireland

Background: Ireland’s General Practitioner-led abortion care system was introduced in 2019 and integrated into existing primary care infrastructure. Objectives: To examine the enabling environment that translated abortion legislation into service delivery. The review identifies barriers and facilitators from the perspectives of abortion seekers, providers, and the healthcare system. Search Strategy: A systematic literature search was conducted in March 2024 across EBSCOhost, PubMed, the Cochrane Library, and Medscape. Of 150 citations screened, 41 met inclusion criteria. The review followed JBI’s convergent integrated approach. Selection Criteria: Eligible studies addressed the operationalisation of abortion care in Ireland, including barriers and enablers. Inclusion required methodological rigour and relevance. No language restrictions applied. CASP, MMAT and JBI tools facilitated appraisal. Data Collection and Analysis: Data were extracted using JBI tools. Quantitative findings were “qualitised” into narrative form and synthesised with qualitative data. Thematic integration was performed across three domains: abortion seekers, providers, and the healthcare system. Key grey literature, including the HSE-commissioned UnPAC study, was also reviewed and informed thematic synthesis. Findings were included if supported by credible or unequivocal evidence. Main Results: Abortion seekers require individualised, compassionate care. Social disadvantage amplifies harm within rigid legal constraints. Providers included enablers and direct deliverers; supporting individual pioneer champions was crucial. Criminalisation and absence of safety zone legislation were chilling factors. Key enablers included hospital support, clinical guidelines, START training, and value clarification workshops. Hospital settings engender more layers of stigma, conscientious objection, and medicolegal complexity. Conclusions: A collaborative, evidence-based service has been implemented, but legislative limitations and persistent qualitative barriers remain. Funding: No funding was received for this study.

Background: Ireland’s General Practitioner-led abortion care system was introduced in 2019 and integrated into existing primary care infrastructure.

To examine the enabling environment that translated abortion legislation into service delivery. The review identifies barriers and facilitators from the perspectives of abortion seekers, providers, and the healthcare system. Search Strategy: A systematic literature search was conducted in March 2024 across EBSCOhost, PubMed, the Cochrane Library, and Medscape. Of 150 citations screened, 41 met inclusion criteria. The review followed JBI’s convergent integrated approach. Selection Criteria: Eligible studies addressed the operationalisation of abortion care in Ireland, including barriers and enablers. Inclusion required methodological rigour and relevance. No language restrictions applied. CASP, MMAT and JBI tools facilitated appraisal. Data Collection and Analysis: Data were extracted using JBI tools. Quantitative findings were “qualitised” into narrative form and synthesised with qualitative data. Thematic integration was performed across three domains: abortion seekers, providers, and the healthcare system. Key grey literature, including the HSE-commissioned UnPAC study, was also reviewed and informed thematic synthesis. Findings were included if supported by credible or unequivocal evidence. Main Results: Abortion seekers require individualised, compassionate care. Social disadvantage amplifies harm within rigid legal constraints. Providers included enablers and direct deliverers; supporting individual pioneer champions was crucial. Criminalisation and absence of safety zone legislation were chilling factors. Key enablers included hospital support, clinical guidelines, START training, and value clarification workshops. Hospital settings engender more layers of stigma, conscientious objection, and medicolegal complexity.

A collaborative, evidence-based service has been implemented, but legislative limitations and persistent qualitative barriers remain. Funding: No funding was received for this study.

Abortion; Barriers; Challenges; Ireland; Policy Implementation Word count: 250

(258 words) The legalisation of abortion in Ireland in 2018 marked a historic shift following decades of highly restrictive policy and constitutional prohibition. Implementing safe, accessible abortion services presented complex challenges, particularly given Ireland’s rural geography, deeply embedded sociocultural conservatism, and the absence of prior domestic abortion infrastructure. In contrast to other jurisdictions that rely on hospital-based or specialist-led models, Ireland adopted a bespoke, GP-led service grounded in the best of international evidence and deliberately eschewing some of the more rigid or outdated conventions seen elsewhere. This approach recognised that early medical abortion can be safely and effectively provided in primary care, and aimed to embed abortion services within familiar, accessible, community-based structures from the outset. The urgency of implementation following the January 2019 commencement of services placed further pressure on policymakers and clinicians to build a novel system on an existing, already-stretched healthcare foundation. Efforts to establish clear clinical pathways, support providers, and ensure public awareness unfolded in real time, under intense scrutiny and amidst ongoing socio-political tension. This mixed-methods systematic review synthesises evidence on how Ireland operationalised its new legal framework into an accessible, nationally available service. Using an enabling environment lens, we identify the policies, structures, professional supports, and socio-political factors that facilitated this transformation, as well as the barriers encountered. Special attention is given to the roles of frontline providers, community-based care pathways, and the integration of advocacy and evidence in shaping policy implementation. Ireland’s model has been described in international commentary as a benchmark for community-based abortion care. A comprehensive literature search across PubMed, CINAHL, Embase, Scopus, and grey literature sources between January 2010 and June 2023 was conducted. Search terms combined key concepts including abortion, Ireland, service delivery, health systems, and enabling environments. Boolean operators and MeSH terms were applied where applicable. No language restrictions were imposed. Reference lists of included studies were systematically reviewed as part of the thesis search process. This led to the identification of the Unplanned Pregnancy and Abortion Care (UnPAC) study—commissioned by the Health Service Executive to inform the statutory review of the Health (Regulation of Termination of Pregnancy) Act 2018. This large-scale, mixed-methods evaluation—incorporating the perspectives of service users, providers, and system stakeholders—was deemed essential for inclusion as a uniquely authoritative grey literature source.

Search Strategy A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, and JBI Evidence Synthesis was conducted. No current or in-progress systematic reviews were identified. A comprehensive literature search followed in March 2024 across EBSCOhost, PubMed, Cochrane Library, and Medscape, using Boolean terms such as “abortion and termination of pregnancy” and “Ireland and Republic of Ireland.” No language or date restrictions were applied due to the recency of legislative change. Reference lists of included studies were screened, leading to the identification of the Unplanned Pregnancy and Abortion Care (UnPAC) study—a grey literature source commissioned by the Health Service Executive to inform policy and service delivery. Inclusion and Exclusion Criteria Eligible studies were peer-reviewed or government-commissioned primary research addressing barriers and facilitators to abortion care provision in Ireland since legalisation in 2018. Studies required clear objectives, methodological transparency, and relevance to abortion seeker, provider, or system-level perspectives. No restrictions were placed on study design. The CASP checklists and MMAT screening tool [1] were applied during initial eligibility assessment. Study Selection A total of 151 citations were managed using EndNote21 and screened via Rayyan. Titles, abstracts, and full texts were independently screened by two reviewers, with disagreements resolved by a third. A total of 41 studies were included. Duplicate entries were merged, and mixed-methods studies were disaggregated as appropriate. Data Extraction and Appraisal Forty-four data sets (quantitative and qualitative) were appraised using JBI tools. Quality thresholds had to be met for inclusion. Qualitative data were extracted thematically and mapped to service user, provider, or system-level domains. Quantitative data were extracted using JBI SUMARI tools for descriptive and inferential analysis. Mixed-method studies were appraised in parallel using appropriate qualitative and quantitative checklists. Data Transformation and Synthesis Quantitative findings were transformed into narrative form (“qualitised”) to enable integration with qualitative findings via the JBI convergent integrated approach. Only findings with credible or unequivocal support were included in the final synthesis. Data were categorised thematically across abortion seeker, provider, and health system perspectives.

Forty-one studies met the inclusion criteria. These comprised 17 qualitative, 11 quantitative, and 13 mixed-methods studies, synthesised using the JBI convergent integrated approach. Findings were categorised thematically into three overarching domains: abortion seeker factors, provider factors, and health system factors. The synthesis reflects perspectives from service users, general practitioners, hospital-based clinicians, and health system stakeholders. 1. Abortion Seeker Factors Abortion seekers in Ireland represented a diverse group navigating a newly established system shaped by law, service design, and stigma. Community-based early medical abortion (EMA) via general practice was a core strength of the model, with localised provision enabling access in many rural areas. However, the responsibility to initiate and coordinate care rested heavily on the individual. The MyOptions helpline functioned as the official triage and referral pathway and was generally viewed as helpful. However, some users reported stress navigating the process, confusion over “open” versus “closed” GP lists, and delays in securing appointments [2]. Service users who did not contact MyOptions directly often encountered non-referring providers or experienced misinformation and stigma during initial consultations [3]. For many, the process felt fragmented and reliant on personal persistence. Women from marginalised or minoritised groups—particularly migrants, those experiencing intimate partner violence, geographic isolation, or social disadvantage—faced amplified barriers at every stage [4]. Stigma, shame, and secrecy continued to shape many abortion experiences. Counselling, while valued by some, was often bypassed or viewed as secondary to the urgent need for access [5]. The default presumption that EMA could be safely and privately self-managed at home did not align with all users’ circumstances. Some lacked privacy, personal safety, or adequate support, and expressed a preference for in-person care or surgical options such as MVA [6]. Demand for method choice and greater agency in care pathways was a recurrent theme. The adoption of telemedicine during the COVID-19 pandemic was broadly welcomed and improved access, particularly for those facing logistical, safety, or economic constraints. Participants described it as a way to avoid transport costs, childcare difficulties, abusive partners, and work disruption [7]. For women accessing care under Section 11 of the legislation due to fatal fetal anomaly, distress was compounded by legal ambiguity and delays in diagnosis. Many faced exclusion from care in Ireland and were forced to travel abroad—experiencing prolonged uncertainty, grief, and residual stigma. Access to timely antenatal screening, compassionate multidisciplinary care, and clear clinical pathways were cited as essential but inconsistent [8]. 2. Provider Factors Provider experiences were shaped by both systemic ambition and structural fragility. Early implementation was largely sustained by individual champions—GPs and hospital clinicians—who took on the responsibility of service initiation amid stigma, legal ambiguity, and logistical uncertainty [9]. These providers often described feeling isolated, exposed, or emotionally burdened, particularly in the absence of institutional support. Crucial enablers included START’s leadership in provider recruitment, peer-led training, and informal mentorship through the START WhatsApp group [10]. These networks offered real-time clinical advice, moral support, and helped to embed a new standard of care into practice. Targeted education meetings, case-based learning, and national training days co-organised with professional bodies (ICGP and IOG) contributed to initial momentum. However, several GPs and hospital staff described this as a “grafted-on” service, rolled out without adequate investment, leading to stress, staff shortages, and scheduling conflicts [11]. Value clarification workshops were frequently cited as helpful for both willing providers and conscientious objectors [12]. These sessions were instrumental in revealing hidden objectors and generating informal workarounds to bridge service gaps. Some objectors were described as “convenience objectors,” citing workload or capacity constraints rather than moral or religious opposition [13]. Hospital-based providers faced more visible stigma, peer scrutiny, and procedural burden—especially when providing second-trimester or MVA care [14]. In contrast, GPs faced greater personal isolation and reputational risk in smaller communities. Concerns were raised about burnout, attrition, and the long-term sustainability of relying on individual providers [15]. Peer cocooning, goodwill from the HSE, and peer affirmation were reported as vital buffers. Trainees, fetal medicine specialists, and providers navigating Section 11 reported additional distress due to unclear legal thresholds and threat of sanction. Many voiced the need for institutional and psychological support, as well as formalised training pathways to ensure service resilience [16]. 3. Health System Factors Ireland’s health system played a pivotal role in shaping the enabling environment for abortion care. National legislation provided a legal mandate, but political will, coordinated leadership, and medical activism—particularly from pro-choice clinicians and representative bodies—were essential to service implementation [17]. Clinical advocates who had supported the Repeal campaign assumed leadership roles in service rollout, shaping both clinical models and public narratives [18]. The GP-led model enabled localised, discreet EMA access in primary care. Early audits confirmed safe, effective community-based care with low complication rates and successful integration with hospital referral pathways [19]. However, service development varied geographically. Hospital and primary care uptake were interdependent; gaps in one sector compromised access in the other [5]. Stigma, conscientious objection (CO), and institutional inertia were more commonly reported in hospital settings. Some hospitals lacked designated pathways or failed to implement care due to staffing shortages, training deficits, or perceived risk. In these cases, CO often became an institutional default. Value clarification workshops helped clarify roles, reduce stigma, and support staff in navigating CO while maintaining patient care [20]. Diagnostic access and referral coordination posed significant barriers. Scanning services varied widely, with some regions dependent on external providers. Women requiring targeted scans often experienced delays and inconsistent communication [15]. These access gaps became more pronounced under COVID-19, which strained resources and introduced new privacy, continuity, and partner support concerns in maternity settings [21]. Later gestation care, including termination for fatal fetal anomaly (TOPFMR), remained highly constrained under Section 11 of the legislation. Diagnostic delays, unclear certification thresholds, and lack of national aneuploidy screening created inequities in eligibility and service timing. MDT sign-off requirements and limited tertiary referral capacity added to provider stress and patient burden [22]. Where abortion was provided, services often relied on peer networks and informal workarounds. Bereavement care following FFA-related pregnancy loss was inconsistently resourced. Studies highlighted the importance of privacy, continuity, communication training, and family inclusion for quality care [23]. The model of care must remain flexible and responsive to clinical realities and patient needs, including ongoing telemedicine, surgical options such as MVA, and resource protections for later gestation care [24]. Barriers Summary Barriers across domains included legal uncertainty, uneven regional access, provider discomfort linked to criminalisation, stigma in hospital settings, lack of safety zone legislation, and insufficient second-trimester capacity. These intersecting issues contributed to variability in both access and quality of care.

Main Findings This review synthesises the evolving evidence base underpinning the development of Ireland’s community-based abortion care model since legalisation in 2018. It confirms that Ireland’s system is built on a foundation of early access to EMA through general practice, with layered support from professional bodies, public health infrastructure, and activist clinical networks. While this model is internationally regarded as innovative and exemplary, the review also identifies persistent access barriers, geographic inconsistencies, and legislative constraints that complicate care delivery. Three distinct yet interlinked levels of influence emerged. Abortion seekers faced amplified barriers if marginalised, often contending with stigma, misinformation, or fractured referral pathways. Providers frequently acted as “individual champions,” navigating institutional inertia, stigma, and limited support, particularly in the hospital sector. Health system factors included the enabling influence of political will and clinician advocacy, but also resource scarcity, CO-related service gaps, and fragmentation in later gestation and FFA care. Strengths and Limitations The strengths of this review include its systematic, protocol-registered design; rigorous critical appraisal using JBI and MMAT tools; and application of a convergent integrated synthesis to merge qualitative and quantitative data. Inclusion of the grey literature UnPAC study added depth by incorporating extensive stakeholder perspectives on Ireland’s service model.

include the small overall number of eligible studies, reflecting the recency of abortion service implementation in Ireland. Variation in study design and terminology introduced some heterogeneity. While the inclusion of qualitative data enabled exploration of values and perceptions, generalisability is constrained. The review focused on the Irish context and may have limited applicability elsewhere. Interpretation (in light of other evidence) Ireland’s experience aligns with international evidence that decentralised, GP-led EMA services are safe and acceptable. As in comparable jurisdictions, barriers rooted in stigma, fragmented referral, and CO impede optimal care delivery. However, Ireland’s reliance on peer-driven networks, informal workarounds, and “champion” providers underscores the fragility of care systems built without dedicated infrastructure or comprehensive training pipelines. International best practice recommends formalised CO policies, equitable access to MVA and surgical options, robust MDT coordination, and telehealth as standard offerings. The review highlights Ireland’s progress in implementing many of these components but also emphasises a continued need for health system investment, legislative refinement, and support for marginalised service users. Critically, the role of START as a grassroots organisation formed by conscientious providers—many of whom campaigned for a ’Yes’ vote in the 2018 referendum—has been instrumental in sustaining the service. START’s contributions to training, mentorship, and clinical guideline dissemination make a compelling case for formalising and funding the organisation within the health system. In parallel, the creation of a dedicated GP Clinical Lead in early medical abortion (EMA) should be considered. Given that the overwhelming majority of abortion care in Ireland occurs in the community, the lack of a formal GP leadership role creates a structural imbalance. GP providers bring distinct insights and operate with different horizon bias compared to hospital-based colleagues, who are more likely to encounter later gestation cases or surgical procedures, often supported by structured academic departments and access to research staff. A GP lead could champion these perspectives, ensure provider concerns are represented, and coordinate peer training, service innovation, and research efforts. As much of the GP-led service delivery is ”invisibilised” in the current research landscape, the role should also include driving research capacity and funding pathways to ensure GP provider contributions are fully recognised and integrated into national data and policy development.

Ireland’s community-based abortion care model is a globally significant example of evidence-informed service design. It has achieved wide coverage and local acceptability in a short time, despite legal and cultural headwinds. However, challenges remain. Legislative ambiguity, criminalisation, stigma, and inconsistent infrastructure create barriers to timely and equitable care. Practical recommendations include: ongoing investment in training and peer networks; expansion of MVA and second-trimester capacity; full integration of telemedicine; strengthened diagnostic and referral systems for FFA care; and formal support for the START network. Consideration should be given to the appointment of a GP Clinical Lead to guide community abortion provision and represent provider concerns in service governance. Research should focus on provider retention, service sustainability, and addressing geographic inequity. Ongoing evaluation, patient-centred design, and responsive policy reform are essential to ensure that Ireland’s model remains resilient, inclusive, and future-facing. Declarations Funding: No funding was received for this study. Conflicts of Interest: Dr. Brian Kennedy is a general practitioner, abortion provider, and abortion care trainer. He is a member of the START network and contributed to advocacy, training, and peer support efforts following the 2018 referendum. These experiences informed the study context but did not influence the review’s methodology or findings. Every effort was made to ensure transparency, rigour, and academic integrity. Ethics Approval: This study was conducted as part of a MSc thesis in Women’s Health and received ethical approval from the University of Buckingham. Author Contributions: Dr. Brian Kennedy conceived and designed the study, conducted the search, data extraction, and synthesis, and drafted the manuscript. Prof. Indu Asanka Jayawardane provided supervision and critical review. Both authors approved the final version of the manuscript.

The authors wish to thank colleagues from the START network and community abortion providers for their informal insights, encouragement, and commitment to evidence-based care.

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Authors Metrics & Citations Metrics Article Usage 205views 142downloads Citations Download citation Brian Kennedy, Indu Asanka Jayawardane. Creating an Enabling Environment for Community-Based Abortion Care: A Mixed Method Systematic Review from Ireland. Authorea. 14 May 2025. DOI: https://doi.org/10.22541/au.174722955.59153904/v1 DOI: https://doi.org/10.22541/au.174722955.59153904/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu.