I thank the committee for inviting me here today to testify. My name is Abigail Aiken and I am assistant professor at the LBJ School of Public Affairs at the University of Texas at Austin. I have been asked to address the committee on international developments in the provision of health care services in the area of termination of pregnancy. I will focus specifically on how these developments have affected the ways in which Irish women access abortion.
Most abortions in Europe take place in clinical settings and are divided into “surgical” abortions and “medical” or “medication” abortions. In Ireland, however, women do not have access to these clinical services and between 1970 and 2016, at least 184,000 Irish women have travelled to England and Wales to access abortion in a clinic. Since 2006 however, a non-profit, online tele-medicine service called Women on Web has provided early medication abortion in countries where safe, legal services are not available. Under this model, a woman fills out an online consultation form, including information about her gestational age, co-morbidities and contraindications. A medical doctor reviews the consultation form and, if appropriate, approves the request and prescribes the medications mifepristone and misoprostol which are used in medication abortion. Both medications are on the WHO's list of essential medicines and Women on Web prescribes them in the dose regimen for medication abortion recommended by WHO.
After the woman makes a donation of between €70 and €90, or however much she can afford, a partner organisation dispatches the medications and they reach her by mail. Once the woman receives the medications, she takes them at home using the clear, simple instructions provided to her by email from Women on Web. Information, advice, and support are provided in close-to-real-time via an online help desk, again through email. All women receive information about the signs of potential complications and instructions for seeking in-person medical attention. Three weeks later, women are asked to fill out an online evaluation reporting the clinical outcome of the abortion and their experiences using the service.
Women in Ireland have been accessing early medication abortion through this online telemedicine model since 2007. Exhibit 1 shows that since 2010, the first year for which data are available, the number of Irish women requesting early medication abortion through Women on Web has more than tripled, from 548 in 2010 to 1,748 in 2016. These numbers include women in both Ireland and Northern Ireland because it is often very difficult to distinguish between the two. Since 2014, other telemedicine services have also been available, so the numbers for 2015 and 2016 are lower bounds.
By contrast, exhibit 2 shows the number of Irish and Northern Irish women travelling abroad to England and Wales. It shows that between 2002 and 2016, the number has fallen by almost 50%, from 7,913 in 2002 to 3,992 in 2016. The number accessing telemedicine has increased and the number travelling to England and Wales has declined.
Who are the Irish women who access abortion through online telemedicine? Exhibit 3A shows the age distribution and 3B shows the parity of women in Ireland who accessed this early medication abortion through Women on Web between 2010 and 2015. This is a sample size of 5,650 women. Members can see that women of all reproductive ages are represented, with the most common age groups being between 30 and 34 years, representing 26% of all requests, and between 25 and 29 years, representing 24% of all requests. Exhibit 3B shows that the majority, 63%, are mothers.
The pregnancy circumstances of the same 5,650 women are displayed in exhibit 4. What members can see is that the majority of women, 54%, were using contraception when they first became pregnant and thus experienced a contraceptive failure. Some 44% of them reported that they were not using contraception when they became pregnant. To put this figure in context, consider that the unmet need for contraception is twice as high in Ireland compared to Great Britain, at 11.2% compared to 5.1%. Finally, only 2% reported requesting early medication abortion due to rape. We know that in Ireland, rape is an under-reported crime. Less than 32% of survivors in 2015 reported that incident to the Garda.
Why do Irish women request abortions? Irish women’s reasons for requesting them through online telemedicine are shown in exhibit 5. We can see that by far the most common reason, cited by 62% of women, is being unable to bring up a child at this time in their lives. We did some in-depth interviews with a sample of these women and they revealed that this category included, but was not limited to, being in a physically or emotionally abusive relationship, being unable to provide for existing children with the addition of another child, and being physically or emotionally unequipped for a pregnancy. These statistics mirror the reasons for abortion among Irish women who travel to clinics in England and Wales. Some 96% of abortions to women who travel to England and Wales are performed under ground C of the 1967 Abortion Act, which allows for abortion when the continuation of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the woman. The remaining 4% of those abortions to women who travel are performed under ground E, for severe foetal anomaly.
In light of the recommendations of the Citizens’ Assembly with respect to the allowable grounds for abortion up to 12 weeks of gestation, it is worth noting that the Irish women who are accessing online telemedicine are under ten weeks of gestation at the time of their request. Similarly, 85% of abortions to Irish women who travel to England and Wales occur at under ten weeks of gestation, and almost all, 92%, at under 13 weeks.
How do Irish women make the decision about whether to travel offshore to England and Wales or access abortion through online telemedicine? Section A, which I will not put up on members' screens but which they have in their packets, shows data from in-depth interviews with Irish women who have used online telemedicine and illustrates some of the reasons women choose this option. Reasons include the significant expense and logistical difficulties of travel, the increased privacy, comfort, and dignity of managing medication abortion at home, and a preference for conducting the abortion at the earliest possible gestational age. Travel is often associated with delays in seeking care; people want to do this early. I cannot give the members all the examples but I will read one given by Mairead, who is 32 years old: She stated:
I really didn't want to travel at all. The whole thing was just so stressful and the idea of having to go to a foreign country on my own and go through it on my own was just horrendous. So, if I'm able to get hold of abortion pills and do it at home that's a better and a much cheaper option. The idea of having to go do it in some random clinic in England is just awful. At home, my friend was able to support me through it all and it made an absolutely massive difference. The idea of having to travel alone and go through that on my own in a foreign country is just unthinkable.
When Irish women choose this online telemedicine model, what are their experiences? Exhibit 6 shows the feelings reported by 1,000 women who went through the early medication abortion with Women on Web between 2010 and 2012. Members should note that these do not add up to 100 because most people chose more than one feeling. By far the most commonly reported feeling was relief - that was about 70% of women - followed by satisfaction at about 36%. Many reported a mix of emotions, for example, feeling both sad and relieved or feeling both loss and empowerment. Among the sample, 98% felt they had made the right choice and would recommend the at-home telemedicine model to another woman in Ireland in a similar situation.
Sections B and C in the qualitative packets show data from in-depth interviews with Irish women documenting their experiences both with online telemedicine and with travel. Women who travelled often struggled to cover the financial cost, which can be over €1,000. They had difficulty finding child care and getting time off work and therefore losing more money that they could not afford, and they experienced stigma and shame, as well as the trauma of managing side effects from an abortion on their way home. One could be bleeding sitting in a plane. To give an example, Emma, who is 24 years old, stated:
So basically when you get to the airport and you get on that flight, it’s kind of known, that this very early flight is the flight people take. You’re waiting to board the plane and you can see the other women and you all know you’re there for the same reason and to be honest, there’s this horrible immediate sense of shame that comes with it and it’s very overwhelming. But the very worst part was when I got back to the airport afterwards and had to wait five hours to get a plane home, sitting there feeling I’d just committed a crime. I was so traumatised by that travel experience I still can’t wrap my head around it.
Women who used online telemedicine instead of travelling commonly describe a contrast between the acceptability of the abortion itself and the anxiety of being found out and potentially prosecuted. I will give members an example from Stacey, who is a 27 year old mother of two. She stated:
The procedure was very straightforward and it did feel very safe with all the information they gave. I had some anxiety that if something had gone wrong, as can happen with any safe medication, it’s hard to know who can I trust - would I incriminate myself? All these things are going through your head because I wasn’t able to do this legally. So, I had all of that extra anxiety.
At-home use of abortion medications obtained using online telemedicine has been demonstrated to be both highly effective and safe. Exhibit 7 is a table showing the clinical outcomes of abortion for 1,000 Irish women who accessed Women on Web between 2010 and 2012. Members can see in the first column that, overall, 99% of women were able to end their pregnancy, and 95% were able to do that without a surgical intervention to help them complete the abortion. These outcomes compare favourably to those for medication abortion, the same type of abortion performed in a clinical setting, up to the same gestational age.
In exhibit 8 members can see the treatment for post-abortion complications among the same group of 1,000 women who used online telemedicine. Overall, 3% received treatment for any adverse event, 2.6% were given antibiotics, less than 1% required a blood transfusion for very heavy bleeding, and no deaths were reported. These complication rates, while still very low, are slightly higher than in the clinical setting. However, since outcomes are self-reported, there is no way to judge whether the appropriate treatment was given to someone or whether unnecessary treatments were given just in case.
Although early medication abortion provided through online telemedicine can be shown to be safe and effective in terms of a clinical outcome, the current Irish abortion law limits the information and support that Irish health care professionals can provide to women. Section D illustrates a variety of experiences that Irish women seeking abortion or seeking follow-up care after abortion have had with health care professionals in Ireland. These range from encountering hostile attitudes, to being provided with inadequate information, to being too afraid to speak to a health care professional for fear of a negative reaction or being reported to the authorities. An example of that is from Adele, who is 29 and a mother of four. She stated:
God no, I couldn’t talk to any doctors about it, definitely not, because I was just so scared. You hear these horror stories of women getting arrested and imprisoned. So, I was completely alone. I did go in when I found at first I was pregnant when I didn't know what I was going to do and I went in and said, “okay, I'm pregnant”, but I obviously never told them any of my intentions. And their reaction was just like, “great, you're pregnant, we'll put you in for your 12-week scan”. But I couldn’t say anything because you don't know how they're going to react.
She could not talk about her thinking or her feelings to anybody because she did not know the reaction she would get.
Some Irish women may be unable to avail of either travel or online telemedicine. Moreover, even those who do manage to access one of them are often in precarious positions in that it is touch and go as to whether they can do it.
Section E in the qualitative packet makes plain the consequences of this lack of access to safe abortion care. Through in-depth interviews, Irish women described the methods they would have had to resort to or which others sometimes would have made them resort to through coercion had online telemedicine or travel not been accessible.
Very unfortunately, these include coat hangers, starvation, high doses of vitamin C, strenuous exercise, large quantities of alcohol, scalding water, drinking bleach, throwing themselves downstairs or running into traffic. Rebecca, who is one example of cases given in a package of information members will have received, is 39 years old and has two children. She explains:
I was walking up to 20 km every day. I was doing sit ups, I was doing squats. I was doing anything I could possibly do to make this happen. I don't think I ate for several days because I had read that if you have an extremely low calorie count and ... [you take] vitamin C that can cause a miscarriage. I was actually reading pregnancy sites that warn you not to do things and everything they were warning you not to do was exactly what I was doing; roasting hot baths to the point that I almost scalded myself, and when I think about it I'm an educated woman, do you know, I'm a grown woman. It's just so sad.
The lack of abortion services within the formal health care system in Ireland means that to access safe and effective care, Irish women must rely either on travel to a clinic offshore or on online telemedicine. Travel carries a significant cost in terms of financial, social, physical, and emotional resources and is out of reach for many. Online telemedicine circumvents many of these costs and is safe and effective, but carries considerable legal risk, which also limits the supporting role Irish health care professionals can play for women when they are faced with these pregnancies. Irish women who need abortions are not restricted to any one demographic group or reason for needing care. Some need later abortions because of foetal anomaly or serious health risks that develop during pregnancy, but the vast majority fall under the broad category where the risks posed to their physical and mental health of continuing the pregnancy outweigh the equivalent risks of ending the pregnancy, and almost all are under 13 weeks pregnant by the time of their abortion. Medically, the gold standard of care would be to legislate for safe, legal, accessible abortion care services throughout Ireland that will meet the needs of the women who need to rely on them. I thank the members for their time.