International Developments in the Provision of Health Care Services in the Area of Termination of Pregnancies: Lyndon B. Johnson School of Public Affairs and World Health Organization

We are now in public session. I welcome members and viewers watching these proceedings on Oireachtas TV. Before we commence our formal proceedings today, I wish to point out that the Honourable Ms Justice Mary Laffoy, Chairperson of the Citizen's Assembly, has written to me to provide clarification in relation to a recommendation of the assembly in respect of reason 13 regarding no restriction as to reason. Members will recall that this matter was discussed at last week's meeting when it was raised by Deputies Rabbitte and Coppinger. In order to clarify the matter I will now read the letter from Ms Justice Laffoy, dated 11 October 2017, into the record.

Dear Senator Noone,

I refer to an exchange that occurred during the committee hearing last Wednesday, 4 October, about the specific recommendation made by the Assembly in Reason 13 on Ballot 48 on the Eighth Amendment of the Constitution.

I am aware you read the exact percentages of that vote into the record subsequently for clarity. However I am aware that some recent media reports may have engendered some confusion on this issue also. As such, I think it would be of assistance if I reiterated the recommendation of the Assembly in regard to Reason 13. The precise wording of Reason 13 was ‘no restriction as to reasons’. The recommendation of the Assembly (by a majority of 64%) was that termination of pregnancy with no restriction as to reasons should be lawful here, but this was further qualified by the Members views on gestational limitations or none. In relation to gestational limits, those Members had further expressed their view on the Ballot as to whether termination of pregnancy should be permitted up to 12 weeks gestation only, up to 22 weeks gestation only, or with no restriction as to gestational age. The option which achieved the highest number of votes here was up to 12 weeks gestation only with 48% voting for this option. Accordingly the recommendation of the Assembly for Reason 13 is that termination of pregnancy should be permitted with no restriction as to reasons, but up to 12 weeks gestation only. According to the resolution approving establishment of the Assembly: "all matters before the Assembly will be determined by a majority of votes of members present and voting, other than the Chairperson who will have a casting vote in the case of an equality of votes". Full details on the voting arrangements and procedure are provided on pages e825 to e828 of the Report, and the Members of the Committee may wish to familiarise themselves with this note, which was provided to the Members of the Assembly in advance of the meeting in April. I hope this provides full clarification on the matter.Yours sincerely,The Hon. Mary LaffoyChairperson

The Citizens' Assembly.

That was for clarification purposes.

Before I introduce our witnesses today, at the request of the broadcasting and recording services, members and visitors are asked to ensure that for the duration of the meeting their mobile phones are turned off completely or switched to aeroplane mode. The gentlemen in our technical department have advised that some phones have been left on, which has caused interference. On behalf of the committee I extend a warm welcome to our witnesses today, who will be addressing international developments in the provision of health care services in the area of termination of pregnancies. We are joined by Dr. Abigail Aiken, assistant professor at the Lyndon B. Johnson, LBJ, School of Public Affairs, Texas, USA and by Dr. Ronald Johnson and Dr. Bela Ganatra, both of whom are from the department of reproductive health and research at the World Health Organization, WHO. They are all very welcome to this afternoon's meeting and I thank them for their attendance.

Before we commence formal proceedings I must advise our witnesses of the situation regarding privilege. By virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to this committee. However, if they are directed by the committee to cease giving evidence on a particular matter and continue to so do, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing ruling of the Chair to the effect that they should not comment on, criticise or make charges against a person outside the House or an official either by name or in such a way as to make him or her identifiable.

I now invite Dr. Aiken to make her presentation.

Dr. Abigail Aiken

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.

I thank Dr. Aiken for her opening statement. I call Dr. Ronald Johnson to make his presentation and he has 12 minutes.

Dr. Ronald Johnson

Good afternoon, Chairman and members of the Oireachtas joint committee. We thank the committee for its invitation to the World Health Organization, WHO, to present our guidance on health system requirements for safe abortion and potential barriers for women wishing to access services.

My colleague, Dr. Ganatra, and I are staff members from the department of reproductive health and research and the special programme of research, development and research training in human reproduction. The department and the special programme provide leadership on matters critical to sexual and reproductive health and rights through shaping the global research agenda, co-ordinating research, setting norms and standards, articulating an evidence and human rights-based approach, and providing technical support to WHO member states on sexual and reproductive health and rights.

The Department’s vision is the attainment by all peoples of the highest possible level of sexual and reproductive health. It strives for a world where all women's and men's rights to enjoy sexual and reproductive health are promoted and protected and all people, including the most vulnerable, have access to sexual and reproductive health information and services. The briefing today falls under our technical support role and through the organization’s aim to support member states to implement the Global Strategy for Women’s, Children's and Adolescents' Health 2016-2030, the strategy on women's health and well-being in the WHO European region, and the Action plan on sexual and reproductive health: towards achieving the 2030 Agenda for Sustainable Development in Europe, which was adopted by European governments last September.

Today’s briefing is about the provision of safe abortion services in the event that some or all of the recommendations of the Citizens' Assembly become national policy. While legal, regulatory, policy and service delivery contexts may vary from country to country, the recommendations and best practices described in WHO guidelines aim to enable evidence-based decision-making with respect to safe abortion care. Today, briefly, we will cover the following points, as described in the WHO guidelines: integration of abortion services into the health system; national standards and guidelines; the equitable distribution and availability of facilities and health care providers; preparation and equipping of health facilities; financing and costs to women; and potential barriers to women accessing services.

Abortion services should be integrated into the health system to acknowledge their status as legitimate health services and to protect against stigmatisation and discrimination of women and health care providers. At a minimum, abortion services should always include medically accurate information and, if requested by the woman, non-directive counselling, to facilitate informed decision-making; abortion services delivered without delay; timely treatment for abortion complications; and contraceptive information, services and referrals.

National evidence-based standards and guidelines for safe abortion should be developed and regularly updated to ensure that health services and standards ensure good access and quality of care. They should cover types of abortion service and where and by whom they can be provided; essential equipment, instruments, medications, supplies and facility capabilities; referral mechanisms; respect for women's informed decision-making, autonomy, confidentiality and privacy; attention to the special needs of adolescents; special provisions for women who have suffered rape; and conscientious objection by health care facilities and health care personnel.

Ensuring access to safe abortion requires the availability of facilities and trained providers within reach of the entire population. Regulation of providers and facilities should be based on evidence of best practices and be aimed at ensuring safety and good quality without compromising accessibility to services. First trimester abortion care can be provided using a simple procedure, vacuum aspiration, or through the use of medical abortion drugs, mifepristone and misoprostol. These interventions can be provided at primary care level and through outpatient services. Such care can also be provided by generalist physicians as well as primary care providers like clinical officers and nurses. In early pregnancy, after the initial assessment by a provider, women can manage the medical abortion process without direct supervision and outside of a facility setting. For abortions beyond 12 weeks of pregnancy, higher level services may be needed, although a surgical abortion can still be provided as outpatient care. Facilities for inpatient care are required for medical abortion beyond 12 weeks of pregnancy. In addition, referral hospitals should have the staff and capacity to perform abortions in all circumstances permitted by the law and to manage all abortion complications.

Abortion facilities and providers must be well prepared and equipped to provide safe care. Most of the equipment, medications, and supplies needed to provide vacuum aspiration are the same as those needed for other gynaecological services. In addition, medical abortion requires registration, procurement and distribution of mifepristone and misoprostol. Supportive services, such as commodity procurement, supply chain functioning and financing mechanisms, are as important as training providers for introducing new services. Where services already exist, infrastructural upgrades can facilitate more efficient patient flow and increase privacy and user satisfaction. Quality approved abortion instruments and medications should be routinely included in the planning, budgeting, procurement, distribution and management systems. In addition to skills training, participating in values clarification exercises can help all health care personnel differentiate their personal beliefs and attitudes from the needs of women seeking abortion services. Values clarification is an exercise in articulating how personal values influence the way in which health care personnel interact with women seeking abortion. Despite health workers’ attempts at objectivity, negative and predefined beliefs about abortion and the women who have them often influence professional judgment and quality of care.

In terms of financing and costs to women, health budgets should include sufficient funds for the following types of costs related to safe abortion: equipment, medications and supplies required to provide care; staff time; training programmes and supervision; infrastructure upgrades; record-keeping; and monitoring and evaluation. The respect, protection and fulfilment of human rights require that women can access legal abortion services regardless of their ability to pay. Financing mechanisms should ensure equitable access to good quality services. Where user fees are charged for abortion, such fees should be matched to women’s ability to pay, and procedures should be developed for exempting the poor and adolescents from paying for services. As far as possible, abortion services should be mandated for coverage under health insurance plans. Abortion should never be denied or delayed because of a woman’s inability to pay.

What are the critical barriers to accessing safe abortion services? Access to safe abortion depends not only on the availability of services but also on the manner in which they are delivered and the treatment of women within the service-delivery context. Services should be delivered in a way that respects a woman’s dignity, guarantees her right to privacy and is sensitive to her needs and perspectives. Attention should be given to the special needs of women of lower socioeconomic status, adolescents, and other vulnerable and marginalised women. Barriers to accessing safe abortion services, even when legal, include the following: restrictive interpretation of legal grounds, including the conditions that fall under health; failure to provide public information on the legal status and availability of abortion; excluding coverage for abortion services under health insurance, or failing to eliminate or reduce service fees for poor women and adolescents; requirements for third-party authorisations from one or more health-care providers, or from a hospital committee, from a court or police, from a parent or guardian, or from a woman’s partner or spouse; restricting the range of health-care providers and facilities, which may result in poor availability of services, especially in rural areas; conscientious objection by health-care facilities and by health-care personnel; requiring mandatory waiting periods; censoring, withholding or intentionally misrepresenting health-related information, in the context of abortion; failure to guarantee confidentiality and privacy; and requirements for medically unnecessary screening tests such as requirements for women to view ultrasound images or listen to the foetal heartbeat. Any of these barriers can deter women from seeking care and providers from delivering services within the formal health system; they cause delays in access to services, which may result in denial of services due to gestational limits on the legal grounds; they create complex and burdensome administrative procedures; they increase the costs of accessing abortion services; and they limit the availability of services and their equitable geographic distribution.

I will conclude by saying that health systems should aim to respect, protect and fulfil the human rights of women, including women’s dignity, autonomy and equality; promote and protect the health of women as a state of complete physical, mental and social well-being; minimise the rate of unintended pregnancy by providing good-quality contraceptive information and services, including a broad range of contraceptive methods, emergency contraception and comprehensive sexuality education; prevent and address stigma and discrimination against women who seek abortion services or treatment for abortion complications; and reduce maternal mortality and morbidity due to unsafe abortion, by ensuring that every woman entitled to legal abortion care can access safe and timely services including post-abortion contraception; and meet the particular needs of women belonging to vulnerable and disadvantaged groups, such as women of lower socioeconomic status, adolescents, single women, refugees and displaced women, women living with HIV, and survivors of rape.

We have provided copies of several documents for every member of the committee. These include the policy brief on law and policy considerations and part of a policy on health worker roles in the health system. We encourage all members to familiarise themselves with the guidelines as well as with our newly-launched global abortion policies database, which has the abortion laws, policies, health standards and guidelines for all UN and WHO member states. One can go into this database to do comparisons and to see the laws and policies in each country. The concluding observations of all of the treaty monitoring bodies are also included in this database and are linked to the countries in question, so one can click on these and go straight to the concluding observations. Country penalties are included, as is a range of sexual and reproductive rights indicators for all countries. One can really get a picture of whichever country one wants in the context of the global community.

There are four lead questioners today and they have ten minutes each. Deputy Durkan has five minutes on this and five minutes on the next speaker if he so wishes.

I thank the witnesses for their very interesting observations. My first question is for Dr. Aiken, who has done a great deal of helpful research in this area. She showed us a chart displaying the number of women who were satisfied after the abortion, including cohorts who felt safe, who felt relieved, satisfied, happy, pleased, and empowered. The chart also showed groups of women who felt guilty, sad, had feelings of loss, felt low, or felt disappointed. To what extent what counselling and support available for that group of women? What was the extent of the follow-up care and what were the findings over the course of that care, if known?

Dr. Abigail Aiken

That is a very good question. When it comes to this graph, it was by no means the case that every woman was completely happy about the abortion. There is often a great mix of emotions and most women, as we can see on the graph, recorded more than one. In response to the question about the counselling made available, the Women on Web service itself has an online email support where women mostly ask questions about, for example, whether what they are seeing is normal and whether they need to get care. They also sometimes ask questions about how they are feeling and whether it is normal to feel the way they do. Women on Web does not, however, provide a full-on and comprehensive counselling service for women. One of the important issues raised here by Deputy Durkan is the fact that women rely on Irish health care professionals for this kind of counselling and I do not know if it is always readily available to them. We can see that many women are scared to talk about this, particularly if they have gone down the online telemedicine route, because of the fear of being prosecuted, reported, or even just stigmatised. What this illustrates to us is that it is very difficult under the law at present to know how to provide those services for the women who are struggling with their feelings after an abortion, even if they are in the minority. My answer then, is that these women do not have full-on counselling through the online telemedicine service and have to go to find it elsewhere. It is not at all clear that the majority are able to do that.

Has Dr. Aiken done any research into the countries with readily accessible abortion services as compared to those, like Ireland, that do not? To what degree does either group of countries rely on online service? How great is that reliance, for example, where abortion is readily available? I presume that follow-up counselling is available in those countries.

Dr. Abigail Aiken

That is another great question. The mission of Women on Web is to provide to countries where safe legal services are unavailable. In a country with readily available abortion service, in Great Britain, for example, most women are accessing abortion in a clinical setting. Some still write to Women on Web, however, because they are in a specific situation where getting to a clinic is very difficult. This may be because of an abusive or controlling partner or perhaps because of a physical disability that makes it hard for them to reach a clinic. The provision of a readily available service, then, does not completely eliminate the barriers to access that some women might experience. It is to the countries where abortion is not legally available through the formal health care system, however, that Women on Web and another online telemedicine service provide. This is where the demand is coming from. There is a correlation between the absence of service in a country and women writing to Women on Web for help. Counselling services are not mandatory in countries like Britain, where very few people need to contact telemedicine services because they have access to clinics. Where such counselling is required or desired by a woman, however, it is fully integrated according to best practice into the abortion care provided.

Deputy Durkan is coming up on five minutes, should he wish to save some time for the second round of questions.

Dr. Bela Ganatra

I support what the Deputy said about the recent global estimates released by the WHO last week with which he might be familiar. They referred to safe, less safe and least safe abortions and their distribution globally. We have found that, by medical standards and WHO guidelines, the self-management of medicated abortion, as described by Women on Web, does fall within the safety criteria and would be considered safe. In Latin America, in particular, where access to clinic services is not available, a number of women are accessing abortion pills online, not specifically from Women on Web which is only one service which cannot reach the majority of women who need a service. They do so through a wide variety of often unregulated services which are of unknown quality. We call such abortions less safe simply because women do not necessarily have access to counselling, adequate information or follow-up care. It is still paradoxical that the mortality rate and the number of deaths in seeking this type of care are much lower than for the dangerous methods mentioned by Dr. Aiken such as the use of coat hangers and bleach. It might hide a situation where women are not receiving appropriate and adequate care, but we do not see it as a public health problem because deaths are not happening. It is, however, something of which we need to be aware and conscious.

I thank Dr. Ganatra. I will save the rest of Deputy Bernard J. Durkan's time for the next session. Deputy Jan O'Sullivan wishes to share her time between this and the next session.

I may use all of it in this session, although I might try to leave a couple of minutes at the end.

The Deputy can suit herself.

I thank the delegates for coming before the committee. I thank Dr. Aiken for the exhibits she has given to us. The give a good human picture of some of the dilemmas people face. I thank the WHO, in particular, because of its international standing. It is really welcome that its representatives have been willing to come and address the committee. I have a number of questions.

I refer to women who use online services to access abortion services. In that context, will the delegates outline their views on whether they think the women in question are entitled to a better level of care in their own health service?

The delegates touched on Deputy Bernard J. Durkan's question. To what extent is there an absence of the care which should be available when there is a risk of illegality? The presentation referred to the issue of cost in the context of excluding women from services.

My related questions are about women who travel outside of the jurisdiction and the health implications in seeking a termination outside one's country. I ask the delegates to respond briefly.

Were the questions directed at-----

They were directed at both delegates. The questions are related.

Dr. Abigail Aiken

I thank the Deputy for her questions, the first of which was whether women were entitled to a better level of care. When we consider online tele-medicine services and travelling, although clearly they are providing abortion services which stop women from having to use coat hangers, bleach and other very dangerous methods, they do not and cannot address all of their needs. Even though online tele-medicine services are very safe and effective, as members will have seen in the charts we have shown, and although women have satisfied feelings afterwards, they still have to avail of such services illegally. The climate of anxiety which hangs over the women to whom we have talked and researched would not be described as quality medical care, given that it is cloak and dagger and there is the threat of prosecution hanging over one's head. They are entitled to better.

Women who travel access services within clinics, but they will still have to manage the symptoms and side effects of the procedure in public as they travel home. Those who live close to services can manage their symptoms quickly at home. There is a disparate level of care between the two systems.

As my colleague pointed out, there should be best practice in abortion services which should be accessible to everybody, regardless of cost and ability to pay, the reason or who someone is. There is a system in place under which women who have the resources and money can travel, although they may not have a great experience. We have heard from many women who had to travel back home while managing symptoms, who had to leave children at home and so forth. It is very difficult to integrate continuity of care when one cannot go to a health care professional, make the decision to have the procedure carried out and receive follow-up care within a continuum in the same health care service. When things are broken up, as is the case for women here, it is very difficult to have a cohesive service which meets everybody's needs.

Dr. Bela Ganatra

From the perspective of the WHO, self-use is a safe option as an active extension of the health system when it is a choice women can make and where they have access to backup care services, if they want and should they need them. When they have to do this because of a lack of options or alternatives, it would not meet the criteria of what the WHO regards as safe. Although one can have a perfectly safe and medically safe abortion by travelling, it still does not reflect an active choice but a lack of safe options and alternatives. It creates inequalities because there are women who cannot afford to travel or who might be too advanced in the pregnancy to travel. It creates inequalities in terms of cost and, most importantly, delays. Although most Irish women who have abortions in the United Kingdom still have them early on, the statistics for the United Kingdom show that the level of abortions beyond 12 weeks is higher among non-residents and Irish women travelling to the United Kingdom than among local residents.

Dr. Ganatra referred to recent research. It may be a document I have read. I would like to ask about comparisons and where Ireland sits with other countries in the rest of Europe and the world in providing access to abortion services, particularly in the context of safe and unsafe abortions to which Dr. Ganatra referred in reply to Deputy Bernard J. Durkan. The research I have read suggests the highest proportions of safe abortions are in certain sub-regions which also show the lowest incidences of abortion. I am very interested in teasing out whether sometimes there is a misconception that if something is not available in a given country, there is not a high incidence of it. I ask for some information on the relationship between safe and legal abortions in other countries.

Dr. Bela Ganatra

Our research and estimates are not broken down by country but rather by region. We do not have specific data for Ireland; we only have data for the region in which it sits. Unfortunately, one of the limitations of the research is the fact that Irish women who travel to the United Kingdom are masked within the sub-regional estimates. The issues specifically related to travelling do not show up in the sub-regional estimates.

On high incidences and safety levels, our information shows that rates of abortion do not vary owing to the degree of restrictiveness of the law. They are similar across the world and regions, despite how strict abortion laws are. The statistics also show that the level of safety changes as the restrictiveness of the law increases. Abortions move from being less safe, in terms of the option of using medication without appropriate information under certain conditions, in particular within the developing world, to the least safe. I would not say Ireland is immune from this based on the data from Dr. Aiken which suggested methods we considered to be the least safe were being used here.

The contrast in this picture is that in countries which have facilitative abortion laws there is often good access to contraception, overall good levels of development and gender equality, thus creating a climate within which women can access good contraception. As a result the rates of unintended pregnancies and abortion are low. When women are faced with a situation where they need an abortion, they can have one safely.

We can have a situation where both low rates and high safety coexist and that, in fact, is the case in northern and western Europe.

Do I have time left?

Yes, you have a couple of minutes.

I will take it so, because I have a question on the practicalities and it is for the WHO. It is on issues that might arise regarding bringing in a legal and regulatory regime. Dr. Aiken dealt with some of this. It is about the practicalities of training, facilities and integrating the system into the current health system. Is that a big issue? How would it be dealt with?

Dr. Ronald Johnson

It is a difficult question, not knowing exactly what is already in place in the Irish context. Generally, as I said in the presentation, to do surgical abortion with vacuum aspiration, most health systems have to have the required instruments and supplies to treat miscarriage and spontaneous abortion or treatment of any sort of complication that might come from it. It is just one step more to provide an induced abortion in terms of cervical dilation or something like that. The added cost should not be that much more. In many countries where there is unsafe abortion there is no question that the costs of safe abortion are much less than treating complications, but it does not perhaps apply to Ireland so much, from what we know in terms of complications.

All of the witnesses have said it is important to have contraception side by side.

Dr. Bela Ganatra

Absolutely.

Dr. Ronald Johnson

The issue with abortion is that it is the end result and we want to encourage countries to deal with the underlying determinants of abortion. Women have abortions because they have an unwanted pregnancy. If we can stop - or reduce, rather, as we cannot stop - unintended pregnancies then we can surely reduce the numbers of abortions. There will always be a need for abortion because contraceptives are not perfect. In the guidelines we have a model where we looked at contraceptive barrier rates and estimated there are approximately 33 million accidental pregnancies every year globally due to contraceptive failure. As Dr. Aiken said, many of the women who have abortions are trying to use contraception anyway. It is a critical component. No abortion service should be provided without offering post-abortion contraception to the women there on the spot.

Dr. Abigail Aiken

I echo what my colleague has said. According to a study that came out last year, the vast majority, at approximately 92% to 95% of people, who used the abortion services of the British Pregnancy Advisory Service, which provides one third of abortions in the country, left the clinic with a contraceptive method. The two services are often very well integrated. Very often, people who have come in who have had trouble accessing contraception or have had a failure from another method leave with a method that works better for them.

Deputy Murphy is indicating that she want to come in briefly on this.

I have a question for Dr. Aiken. Is it fair to say women using Women on Web might not disclose an underlying health condition because they risk not getting the medication, which may well put them at risk? How is this evaluated? Is it evaluated afterwards? What controls can be put in place?

Dr. Abigail Aiken

Women on Web relies on women filling in the online consultation form to give truthful consultations. Committee members have the full study, and can see the table which shows that very few women have any contraindications or comorbidities, and when they do, a doctor reviews it and has communication with the woman to try to work out a strategy to make it safe for her. There is very little incentive to lie about these things because women know that Women on Web is their option. Women who cannot access it are more at risk of trying something more dangerous, as we have seen from some of the consultations today. I do not think people generally are untruthful about these things, but it would be much better if they could come and see health care professionals in person.

The Deputy has nine minutes left on the next session. I will now go to Deputy Chambers, who has indicated five minutes on this and five minutes on the next session. I will let her know when the time is up.

I thank the witnesses for their presentation and engagement. My first question is for Dr. Aiken. I only became aware of Women on Web this year, and I was surprised to see it has been operating for so long. Increasing numbers are using the service. Does Dr. Aiken attribute the decline in people travelling directly to the increase in the number of women using the online service? The research has touched on very personal aspects. Dr. Aiken has spoken to women, engaged with those who have used the service and ascertained why they did so and how they felt afterwards. This is really important information for us to have, to speak about the people who are actually affected and what has happened to them and why they went there.

All the witnesses have touched on the issue of contraception. Do we need to do more in this country with regard to access to cheaper contraception and making it more widely available and having better education? Obviously, prevention is better than cure and perhaps we are failing in that aspect.

There is a little bit of interference. I wonder if there is a mobile phone near the microphone.

I am also particularly concerned about the example of Stacey, who spoke about her fear of not knowing who to trust and to whom she could talk. That is a major concern for us in this country. Should a person access services online and something goes wrong, and thankfully the figures have shown this does not happen very often but it does happen, how does Dr. Aiken view the criminalisation of taking the pills, in terms of the safety of women and girls in this country? The last thing we want is for a woman to be at home and experiencing complications and waiting and not seeking medical help. That is something we really need to address.

These are my questions for Dr. Aiken and I will direct my other questions to Dr. Johnson and Dr. Ganatra.

Does Deputy Chambers want Dr. Aiken to answer now?

It makes no difference.

Dr. Abigail Aiken

The Deputy's first question was whether the decline in the number travelling and the increase in the number accessing pills through Women on Web are related. If we look at the graph, exhibit 2, we could not put all of the years on the axis, so 2002 is the first year in the graph, which is the first year of the decline. This decline has been quite steady to 2016. Committee members will notice there is some compression on the axis between 2002 and 2009 so it looks steeper than it should be in the first part. The first years on the graph were prior to Women on Web becoming available in 2007. Of course, it took a little while for the service to get known and for people to start using it.

What we can say is there was a decline in people travelling even before Women on Web came along, but we see from the graph, exhibit 1, there was a tripling over the past six years. It could certainly be that some women are making a decision that it is better for them to use the online service than to travel. What could also be happening is there is a group of women for whom travel was never a possibility, that it was simply out of reach because it was too expensive or they could not get away from home or tell anyone. For these women it is possible the online service has allowed them a way to access abortion that was not there for them before, if that makes sense. Although the decline could be linked, we cannot attribute it to one replacing the other.

The Deputy's next question was on contraceptive access in Ireland. It is the case, no matter whether one is privately or publicly insured in Ireland, that one will have a co-pay for prescription medication, and this includes contraception. If we look at the figures released by the Irish Family Planning Association, someone could be looking at €30 a packet of contraceptive pills times 12 times however many years they will be used for, so there are co-pay problems with access to contraception for most people. People looking to get an intrauterine device, IUD, such as Mirena, could be looking at an upfront payment of €350 to €400. There are still some access problems, and this is reflected in the unmet needs statistic, where the unmet need for contraception in Ireland is double that of Great Britain where those medications are free of cost to everyone.

As my colleague pointed out, even with better contraceptive services, and absolutely that is something to focus on, the need for abortion still does not completely go away. It can certainly help with reducing abortion rates, but the two things really are hand-in-hand services that both need to be encompassed.

The Deputy's final question was about criminalisation and safety. We do see from the exhibits that the outcomes in terms of safety from Women on Web and other online services are good. One thing that is not in the charts is that among the about 9% of women who experience the symptom of what could have been a complication that was serious, 95% of those women did report going to a hospital and seeking care. Those who did not, which was about two people, were okay; nothing bad happened to them so from the data we have, people do go when it is necessary. However, this does not mean that it is easy for them to go and it does not mean that they might go when something is not an absolute emergency but they still might need some care. They might need some follow up, they might need to talk to someone, they might need counselling or they might need to go for something that is not necessary going to cause mortality but could cause morbidity so criminalisation still stops people from talking to health care professionals, interrupts that doctor-patient relationship that should be happening and stigmatises even if it is does not always stop people seeking emergency care. When one stigmatises something and makes it seem wrong, one puts it behind a door so it is no longer in the open.

I have one final question for the witnesses from the WHO. Again, it relates to decriminalising abortion, particularly because we are looking at people accessing the abortion pill, which is technically a crime. The Citizens' Assembly did not recommend this but it did not take a vote on it and it did appear in some of its closing remarks from individual members. Do the witnesses think it is important that this committee discusses that and recommends decriminalisation? If we want to reduce the number of crisis pregnancies or unplanned pregnancies, what do we need to do in terms of addressing the issue? As Dr. Johnson said, one of the ways we could reduce abortions is by reducing unwanted pregnancies. Have they any suggestions beside contraception about what we should be doing to tackle that?

Dr. Ronald Johnson

There are different levels of criminalisation. In Ireland, there is the criminal law but it is maybe not as enforced as often as it is in other countries. Even when one does not have enforcement, criminalisation creates a chilling effect on women seeking services because they are never quite sure if they might go to prison for it. It also creates a chilling effect on providers providing services, again because they are unsure of what might happen. It can be worse if the laws are actually applied. I am sure members are all familiar with the situation in Romania back in the 1990s. Abortion was legal up until 1966. When it was criminalised in 1966, it was not just a policy matter. Many measures were put in place to enforce it. The importation of contraceptives was prohibited and people were sent to high schools to do gynaecological checks of young girls every month and if girls were found to be pregnant, they would follow them up, so it was seriously criminalised. Members can see the graphs. Abortion-related mortality skyrocketed to some of the high levels we have ever documented. In 1991, the law was liberalised overnight. Ceauescu was executed and the first thing the Romanian Government did was liberalise the law because it recognised the problem of unsafe abortions. Members can see that overnight, the mortality rate dropped considerably. The number of abortions went up because they had not been reported before and all of a sudden, women had access to safe abortion, but members can see that the number came down as contraception use went up because they started increasing contraceptive access. In addition to contraception, we also need comprehensive sexuality education. That, coupled with access to affordable contraception, is the best way to prevent unintended pregnancy.

I thank all three witnesses for very their interesting presentations. I will start with the presentation from the witnesses from the WHO. They stated that there is no difference between abortion rates where abortion is legal or illegal because we regularly hear claims in Ireland from people who oppose abortion that it saves lives. We have heard the claim that it has saved 100,000 lives. Based on the witnesses' study of countries around the world, do they agree or would they still put forward the argument that there is no difference in abortion rates?

Dr. Bela Ganatra

There is no statistically significant difference in abortion rates based purely on the association of the restrictiveness of a country's laws. Abortion rates are, of course, significantly lower in the developed world and Europe - they have declined over the past 25 years - than they have in developing countries. It is not one on one because a number of factors determine the rates of abortion but when compared by legal status, we did not find that rates varied based on how restrictive laws were.

Would Dr. Ganatra agree that in Ireland, we are very lucky that due to our close proximity to Great Britain and the availability now of telemedicine sites we do not have the type of backstreet abortions and unsafe things Dr. Ganatra has seen in other countries where abortion is banned?

Dr. Bela Ganatra

I would say that Ireland has been incredibly lucky not to have witnessed the mortality and the consequences we have seen in other places such as Africa but the WHO's definitions of "safe" and "unsafe" take into account the fact that services have to be available and women have to have information and choices. It is not about whether they die or have severe consequences. It is the conditions under which women can access care that make an abortion safe or less safe, so I do not think just the fact that women are not dying means that no problem exists.

I thank Dr. Aiken for giving voice to a lot of women in this country who are virtually silenced and at least bringing out their testimonies through her research. I want to ask her about a study by the University of Kent in March 2016 by Dr. Sally Sheldon. Dr. Aiken is obviously referring to Women on Web but Dr. Sheldon's study referred to two sites - Women on Web and Women Help Women. Dr. Sheldon reckons that there were 3,000 requests from people in Ireland to those sites alone every year. If we break that down in figures, which is really important for an accurate abortion rate in this country, let us say 70% of them came from the Republic of Ireland which would mean that 2,100 requests for abortion were made through these two sites in the South. If we divide that by 52 weeks, that is roughly 40 requests per week. Let us say only 35 of those people actually carry it out because not everybody who orders the pills goes through with it - some people change their mind - that would be 35 women every week, which would be five per day in the Republic of Ireland/ That is a much higher figure than anybody would ever have contended. Would those figures be accurate based on Dr. Aiken's research with just one site?

Dr. Abigail Aiken

As I stated when we looked at the exhibit that showed the tripling between 2004 and 2016 for Women on Web, we cannot do the same thing for both services because Women Help Women began in 2014 so, as I stated, those figures for 2015 and 2016 are lower bounds because they show figures for Women on Web only. I am glad that Deputy Coppinger drew attention to the fact that Dr. Sheldon's study looked at 2015 and 2016 and was able to come up with that estimate of 3,000. When one breaks that down by the number of people, that is probably is per day and the rate of people who maybe do not go ahead and carry it out, I think five women per day would be quite an accurate statistic. One must then add the people who travel to that.

The last question concerns the reasons women gave for having abortions. Dr. Aiken said the most common age group was 30 to 34-year-olds and the second was 25 to 29-year-olds. A myth that is often put out is that if it became available, it would be a case of young single girls out on a Saturday night popping in for an abortion on the Monday, the concept of abortion on demand.

In fact, however, 63% are mothers already. These are women who know what it is like to have children, have experienced pregnancy already and have decided that they cannot cope at this time with another child, which the witness said was the most common reason. The second most common reason was money. That puts paid to the idea people will be popping out every week to have one if it is made available.

On rape and fatal foetal abnormality, the witness said approximately 2% of people cited rape as the reason. I think she said that fatal foetal abnormality was the reason in 4% of cases in the UK. That would be 6% of abortions in Ireland. Some people are talking about those two reasons only for the basis of legislation in this country. How would she feel if the 94% of abortions, which the witness tells us are done in the timeframe of 13 weeks anyway, were not catered for? Will women still have to rely on websites?

I thank Deputy Coppinger. I apologise to the witness but I have to ask her to be as brief as she can with the responses because we are already overtime and many people have indicated that they wish to come in.

Dr. Abigail Aiken

I will be brief. When we consider the graphs - exhibit 3A and exhibit 3B - we see that abortion in Ireland is not restricted to any particular group of women or reason. Although cases of foetal anomaly and rape are the ones that are often talked about a lot, as they tend to be at later gestations, especially with foetal anomaly because those are not usually diagnosed until the 20-week scan, we are talking about the small number of abortions that happen at a higher gestation. As we said, the vast majority of abortions to people in Ireland are happening at 13 weeks. If those abortions - those 94% - do not form part of the conversation about what to do about abortion in Ireland, most of the problem that exists will not be addressed.

I thank Dr. Aiken. Senator Ruane has six minutes.

I thank both of the witnesses for their presentations. Both presentations speak for themselves. They were thorough. I have two questions. One is for Dr. Aiken and the other for Dr. Ganatra to answer. In Dr. Aiken's presentation, she stated that 54% of women experience a contraceptive failure and sought abortion access as a result. We spoke a little here about the importance of contraception and how it should be integrated in terms of abortion care as well. Can Dr. Aiken speak further to the relationship between contraception and abortion and, in particular, the accuracy of the claim in some quarters that women may use abortion as a primary form of birth control in a liberal abortion regime?

My second question is for Dr. Ganatra. In her presentation, she stated that one of the barriers to safe abortion services is the intentional misrepresenting of health-related information on abortion. In Ireland, many cases have arisen recently where rogue crisis pregnancy counsellors have given inaccurate and misleading information to women. Can Dr. Ganatra describe a best practice framework for how such services should be delivered and regulated to minimise any further risk of this?

Dr. Abigail Aiken

As I showed in the presentation, 54% of those women - the majority - had been using contraception at the time that they became pregnant. We know that contraception is not 100% effective. No method is. There simply is not one. However, if we consider countries, for example, Great Britain, where full abortion services are available to most people, we can see that the unmet demand for contraceptive use is lower than in Ireland. It is half the rate. Therefore, there really is no empirical evidence to support the claim that people would stop using contraception if abortion was available. If we consider Great Britain and other countries that have liberal abortion laws and their rates of contraceptive use, they are higher than the rate of contraceptive use in Ireland. I have no empirical evidence to support that kind of talk.

Dr. Bela Ganatra

If one looks at the graph, it shows how abortion rates have consistently declined in Europe between 1990 and 2014, and the majority of the countries have abortion laws that are fairly liberal. To address the concern about the misrepresentation of information and the setting-up of services, the key point would be to have national standards and guidelines which lay out clearly what the responsibilities are, how services should be delivered, how the legal grounds need to be interpreted and what are the medical standards.

I call Deputy O'Connell.

I thank the witnesses for attending today. My colleague, Deputy Durkan, referred to the slide - perhaps it could be displayed - with the feelings after abortions, including guilt, sadness, feelings of loss, low, and disappointed. I would assume that there is a correlation with the same feelings someone would have after a miscarriage. Are there any comparative data? Is data available to compare whether women have similar feelings after a miscarriage? I am trying to work out if there is a difference in that regard. There is no reference to a term that is thrown around a bit, which is "abortion regret". Was that considered or is that just one of those made up things? Could the witnesses qualify that for me?

On the evidence from Women on Web, have we any evidence that women are procuring pills online and saying that they are under ten weeks pregnant when, in fact, they are 14 or 16 weeks pregnant? Have we any data to show the complications that might arise out of off-licence use of the product and long-term health implications if a woman takes it too late?

Looking at this from outside Ireland, as the witnesses do, in an international global context would the approach taken by consecutive Irish Governments to women's policy be considered quite primitive? Are they surprised that as a modern country we are having this conversation here today? I cannot believe we are having these conversations, but we are.

To clarify some of the matters-----

Perhaps the witnesses could respond to some of those questions because there were a number of questions there.

Dr. Abigail Aiken

No, I do not have data on feelings after miscarriage. I am sure there are papers available on it. However, I do not have that, especially not to compare to these women. On abortion regret, the data in front of the Deputy is really the best data we have. It is from 1,000 women and looks at their feelings after an abortion. I think there are as many feelings after abortions as there are abortions because it is an individual and personal thing. However, looking at this graph, I do not see much evidence for an abortion regret. I know it is a term that is out there but it does not really exist in the medical literature. I have to emphasise that we really lack empirical evidence - real evidence - that it is actually a thing.

On whether people tell the truth about being ten weeks pregnant or under, I do not think we would see the kinds of outcomes that we see in exhibit 7 or exhibit 8 if people were being untruthful about their gestation. It is not as though people drop off some kind of a cliff after ten weeks, where it will all go terribly badly wrong. It really is a kind of a dose-response, where the further one goes the more likely one will need surgical help ending the abortion or to see some kind of a complication. It really is not a kind of a hard cut-point. That is just where the trials end, so at the moment that is where evidence goes to. If women were not telling the truth about this and not following the instructions they are given by the online telemedicines service, we would not see anything like the effectiveness rates that are there or the low rates of complications. This tells us people are generally following the instructions that they are given and not taking risks with their health. People generally know what is best for them when it comes to their health.

I will pass to my colleagues for the next question.

Dr. Ronald Johnson

The World Health Organization would never say that Ireland is living in the dark ages. Ireland is an outlier in the European region in terms of its abortion laws. However, every country has its unique historical context and social and cultural differences. The economics are different and the politics are different. All these differences are important in helping to explain the current situation. Regardless of that, women will have abortions. Therefore, Ireland has to ask itself if it wants to change anything at this point. If it does, the World Health Organization would be more than willing to engage with the Department of Health.

We would really like to support Ireland to adapt our evidence based and human rights based approach.

Finally, what approach would Dr. Johnson advise this committee to take in considering and making recommendations on gestational limits? We have discussed the fact that there is only 6% between fatal foetal abnormalities and rape, which leaves 94% to be dealt with. I would have concerns, based on the evidence we have heard at this committee to date, about how we can insert into legislation a requirement that people prove that they have been raped in order to access abortion. Has Dr. Johnson any advice for this committee on how we might proceed when it comes to setting gestational limits if we are going to have abortion in Ireland?

Dr. Ronald Johnson

We have looked at gestational limits in our policies database and found that across the world, they range from eight weeks - and in this particular country, it is eight weeks to save the woman's life - up to no limit and everything one can imagine in between. If one looks at the database, one sees that in some instances, the numbers are ad hoc or arbitrary. I do not know why particular limits are set. It may have to do with trimesters of abortion. A lot of countries settle at around 12 weeks for on-request abortion but there is a group of countries at 14 weeks, another group at 18 weeks and then some are at 24 weeks. There are four countries with no limits.

The other point about gestational limits is that they vary by country for different legal grounds. There are gestational limits for abortion on request, without specification of reason. About 92% of countries have gestational limits that have abortion on request. When it comes to health, about 37% of countries have limits, with the rest having no limit. When it comes to life, about 20% have a limit, with the rest having no limit. Again, one must anticipate that whatever limit one sets, some woman will need an abortion who will be beyond that limit and one must ask oneself what that woman is going to do.

Deputy Jonathan O'Brien is next. I must ask members to be as concise as possible with their questions.

I just have two short questions for the representatives from the WHO. Is there any correlation between gestational limits and safe abortions? One of the difficulties we are faced with in terms of legislation based on the recommendations of the Citizens' Assembly is that the assembly referred to "risk", "serious risk" and "real and substantial risk". Does the WHO have any definitions for "risk" and "serious risk"?

Dr. Ronald Johnson

Okay, we will both give a quick response to that. Abortion is a very safe procedure. It is safe at any gestational limit but it is safest very early. There is some excellent data from the USA - Centre for Disease Control, CDC, data collected over a ten year period - which shows that the mortality rate is about 0.6 per 100,000 abortions at 21 weeks or more. All of that needs to be put into the perspective of the fact that abortion is still safer than carrying a pregnancy to term. The average abortion is about fourteen times safer than carrying a pregnancy to term. That helps to put it into perspective. Abortion is a very safe procedure. However, risk increases exponentially for every week, even though the numbers are very low. It makes sense, from an evidence point of view, to do it as soon as possible.

Dr. Bela Ganatra

Does Dr. Johnson want to address the risk question too?

The Citizens' Assembly gave us a number of options in terms of risk.

Dr. Ronald Johnson

The WHO does not define "severe risk". We just talk about risk and health risk. Is this in the context of health?

That is correct, yes. The Citizens' Assembly gave us a number of options including "risk", "serious risk" or a "real and substantial risk". I am asking how we would go about defining that in legislation.

Dr. Ronald Johnson

What the WHO says about that is on page 92 of our guidelines, as follows:

The fulfilment of human rights requires that women can access safe abortion when it is indicated to protect their health. Physical health is widely understood to include conditions that aggravate pregnancy and those aggravated by pregnancy. The scope of mental health includes psychological distress or mental suffering caused by, for example, coerced or forced sexual acts and diagnosis of severe fetal impairment. A woman’s social circumstances are also taken into account to assess health risk.

In many countries, the law does not specify the aspects of health that are concerned but merely states that abortion is permitted to avert risk of injury to the pregnant woman’s health. Since all countries that are members of WHO accept its constitutional description of health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”, this description of complete health is implied in the interpretation of laws that allow abortion to protect women’s health.

If we were to draft legislation which used the terms "serious risk" or "severe risk", we would not be in line with the WHO guidelines because the latter only refer to "risk". Would that be fair to say?

Dr. Ronald Johnson

I think one has to ask oneself, "How will this be defined?"; not only how it will be defined in the policy but how it will be applied in practice. At the end of the day, if a country does not have abortion on request without specification of reason, then the person who decides about the abortion is a third party; it is the health care provider. Not every health care provider thinks the same way. The criminalisation aspects and everything else will determine which ones are willing to broaden their interpretation of grounds. Some will do so but others will not. The question is, "Is that fair to women, if one health care provider will take an expanded interpretation and another will not?". Those are the kinds of questions that one has to ask when one starts talking about these qualitative terms that are not precise.

Dr. Bela Ganatra

It is also that risk is determined post-event. It is afterwards that we decide that something was serious or not serious. One cannot anticipate whether a particular health or medical condition is actually going to become worse as it is happening. It is a case by case decision that cannot be anticipated and written about beforehand.

Senator Rónán Mullen is next.

My first question is for the first speaker from the WHO. Would I be right in thinking that he would support a law requiring those providing abortion to offer post-abortion contraception? Would he support a law that would make it a requirement for them to offer post-abortion contraception, given that he spoke about how important he thought that was?

Dr. Ronald Johnson

It is incredibly important.

I would like a short answer.

Dr. Ronald Johnson

It should be offered. In terms of a law, it would depend how the law is written because one does not want to force women-----

No, I am talking about requiring the practitioner to offer it.

Dr. Bela Ganatra

That would be good medical practice and-----

I find it surprising then that on the other hand, the WHO representative would have a problem with a law that would mandate that women would be offered ultrasound possibilities, foetal heartbeat monitoring or indeed, accurate information about possible mental health sequelae that apply in some cases. I am not speaking about mandating that but requiring that it would be offered. I thought there was such a thing as informed consent.

It is concerning that the delgates seem to deprecate anything that might lead a woman to change her mind about having an abortion, but they are very happy to be prescriptive on the question of whether a good law would be required for a post-abortion contraception service to be offered. I thank them for their answer in that regard. Let me move on to ask another-----

Excuse me, Senator, I am chairing the meeting and I would like to give the delegates the opportunity-----

I am anxious to cover quite a bit of ground. Will the Chairman afford me some leeway afterwards? It is my entitlement to seek answers.

Certainly, but I think the delegates wished to answer the question.

I have no problem with that, but, please, do not cut me off because I need to cover some ground.

The Senator is supposed to be asking questions to get answers. With respect-----

I got the answer.

Dr. Ronald Johnson

Something needs to be corrected. We did not say "offered"; we said "forced". When it should not be forced-----

Therefore, Dr. Johnson would have no problem with a law that would require people to be offered ultrasound opportunities to hear about possible mental health sequelae and the possibility of hearing the foetal heartbeat? In the context of informed consent, he would have no problem with that being offered in a respectful way but one that accepts a possible refusal of the offer? Is that Dr. Johnson's position?

Dr. Bela Ganatra

The scientific-----

I just want a yes or no answer. It is a straight question.

Dr. Bela Ganatra

Medical practice is best not regulated at this level in law, whether for contraception or anything else.

Dr. Bela Ganatra

It is best determined by a medical practitioner.

I note the contrast in the delegates' answers. I turn to their claim, without producing evidence in front of us, although admittedly they did not have time to do so, that there is no evidence that a restriction in the law causes a lower incidence of abortion. Is it not strange that Britain which has a population roughly 15 times the size of Ireland's - 60 million compared to 4 million - nonetheless has an abortion rate at least 30 times the rate for Ireland? In Britain there is something short of 200,000 abortions a year. Borrowing Deputy Ruth Coppinger's figures for the likely incidence of abortions induced by medical pills, Ireland might have a figure of 6,000 a year. I find it difficult to understand how in their presentation the delegates did not address that glaring statistic.

I draw the delegates' attention to something that came up last week on which I was challenged, but I was correct. It is that in Northern Ireland which has a smaller population than the Republic the Advertising Standards Authority upheld a billboard campaign that claimed that there was a reasonable probability that approximately 100,000 people were alive in Northern Ireland who would otherwise have been aborted had it been legal to do so. It stated, "On balance, we concluded that the evidence indicated that there was a reasonable probability" and "Because we considered that readers would understand the figure to represent an estimate, we concluded that the claim was unlikely to materially mislead readers". A similar conservative estimate has been made about the impact of Irish constitutional law. Would the delegates from the WHO accept that they are making a claim that seems bizarre in the light of the disparity in the abortion figures for Britain and Ireland?

Dr. Bela Ganatra

To clarify, we do not have country by country comparisons of abortion incidences. We have noted that we have data at sub-regional level and that they might mask what happens in Ireland, but we know from the research and other countries too that in circumstances where abortion is illegal, stigmatised and happening outside formal health services, the numbers are obviously not counted or well accounted for and abortion incidences could be completely under-reported, whereas in Britain there are extremely good statistics and reporting on the data. I do not think the comparison would be-----

I thank Dr. Ganatra for her answer. Let me draw her-----

Dr. Bela Ganatra

Dr. Aiken will answer the rest of the question.

I did not address her.

Dr. Abigail Aiken

May I quickly speak?

Dr. Abigail Aiken

I will address the figure of 100,000. I have seen the billboard in question. A problem with the figure is that when one looks at the methodology of how it is calculated, it has taken the abortion ratio for Scotland between 2008 and 2012 and applied it to Northern Ireland from1967 onwards. In 1967 when abortion services first became available, not everyone rushed at once to have one. The methodology has taken a ratio from a different country that is too large and applied it to Northern Ireland. I agree that the Advertising Standards Authority upheld it, but there are many problems with the figure.

It is not that I do not want to give people an opportunity to answer my questions fully, but we are involved in a really restricted process which makes a nonsense of the life and death issues with which we are dealing. I am trying to cover important ground.

The preamble to the Convention on the Rights of the Child-----

The Senator may make a final point of clarification.

I wish to ask the delegates from the World Health Organization for their views on two very important matters. The preamble to the Convention on the Rights of the Child of 1989 cites the Declaration of the Rights of the Child of 1959. It states the child "by reason of his physical and mental immaturity, needs special safeguards and care, including appropriate legal protection, before as well as after birth". Does the delegates' presentation, in which they talk about how incredibly safe abortion is without once acknowledging that it is anything but safe for the unborn child, not make a nonsense of what is stated in the preamble?

Late-term abortions happen in places such as Britain and Canada where quite a number of botched abortions have taken place in recent years and where children were alive after the procedure. What is the delegates' view on what should be done in that case? What do they think happens and what do they think should be done to provide pain relief for unborn children, if they have prescriptions to give us in that regard? I notice how unprescriptive they were in talking about gestational limits. It was remarkable compared to how prescriptive they were on the need to allow abortion wherever one was wanted. It makes me wonder whether they have ever observed an abortion taking place to see what is involved.

The Senator will have to allow the delegates to respond. We have nearly reached nine minutes and need to be fair to everybody.

I appeal to the Chairman, given the seriousness of the issues involved and the imbalance in the committee's membership in the points of view held on this issue and also among those invited to address the committee, to at least show me the courtesy of affording me leeway.

I have afforded the Senator leeway.

Where is the imbalance? It is not.

I do not wish to get into a debate on that issue in the presence of the delegates. We are trying to make the best use of our time. I ask the delegates from the WHO to respond as briefly as possible.

Dr. Ronald Johnson

I do not think what we have said makes a nonsense of the statement made in the Convention on the Rights of the Child. I do not think that statement addresses the interests of the foetus in the context of those of the woman.

Dr. Bela Ganatra

There is an issue with unsafe abortion, given the rise in the number of unwanted pregnancies among young adolescent girls who do not have access to safe abortion. The incidence of unsafe abortion is much higher in that age group. If one is talking about protecting children, one has to talk about ensuring access for adolescent girls also.

The preamble refers to the protection of the child before birth.

Dr. Bela Ganatra

I think Dr. Johnson has already answered that question. I do not think we have any evidence of foetal pain about which the Senator is talking.

Without making points, the discourtesy shown to people whom we have invited is unacceptable, regardless of their views. There should be an intervention to deal with that issue. It is not on.

On a point of order, I showed no discourtesy to anybody. I asked questions forensically and sought the right to persist in asking a number of questions. I object to fellow members of the committee seeking to up the ante in this way in dealing with what is a very sensitive issue of human rights and human dignity. I will make contact with the Chairman to put these objections more clearly without taking up more time today.

I would like us to use our time as well as we can and ask Deputy Clare Daly to pose questions to the delegates. We will note her comments and return to the matter at another time.

I find the information provided incredibly helpful. Some of my questions have been answered and I will ask a few more.

It is quite obvious that, regardless of our deliberations, the use of abortion pills by Irish women will continue and actually increase. The delegates have given us evidence that it is safe and cheaper. Has any analysis been made against the backdrop of criminalisation, the threat of arrest and prosecution in Northern Ireland, for example, or here, to show that people are because of this prospect putting off this more convenient or easier to access option and instead travelling at greater expense and inconvenience?

Is it the view of the witnesses that for us as a committee to look at this issue and not to take on board decriminalisation we would be only doing half the job? Related to that is the fact that we have a module for dealing with ancillary recommendations. It strikes me, based on what the witnesses are saying, that we would be doing an incomplete job if we did not look at the whole area of contraception. It is utterly shocking to think that 44% of people are not using contraception. We have a huge problem in this country in not supporting people and dealing with the issue of unplanned pregnancy. Do the witnesses think that in order to deal comprehensively with abortion, we need to take those two aspects into consideration in our findings?

Dr. Abigail Aiken

In terms of decriminalisation, there is no evidence at present that women in Northern Ireland, where there have been some prosecutions, have decided that they will travel instead because so often travel is out of their reach. Although it is an option that risks prosecution, it is the option. If the committee did not deal with decriminalisation one of the problems is the lengths to which women for whom travel or even abortion pills might be out of reach will resort to end their pregnancy. Those things are also covered under criminal law. If the committee did not take that into account its members would still have to worry about those people who end up doing things that are blatantly unsafe because they are not able to access any other kinds of services.

On the contraceptive question, again, if one looks at the co-pays that women are having to pay to keep contraception going between the approximate ages of 15 and 45 when they are potentially able to get pregnant, the cost adds up to quite a lot of money and if trying to break down the barriers to contraception is within the ancillary recommendations that would be a very sensible thing to do.

I was struck by Dr Ganatra's point about the issue not being about death or serious ill health to the woman, but that one looks at the question on the basis of the conditions under which women can access health care. That struck me as quite important. How does the WHO classify the issue of health and the definitions one uses in that regard? Based on what has been said Ireland would be very much out of kilter in terms of some of the guidelines in regard to this area of women's reproductive health. Does Dr. Ganatra know if Irish medical policy and practice generally follow the WHO guidelines in terms of other areas of women's health? Perhaps she could give more information on how she came to those views because there was an inference at last week's meeting of the committee from one of our contributors that there is an international conspiracy of pro-abortion advocates who have taken over international organisations to promote an abortion agenda. Could Dr. Ganatra deal with that inference? How did the World Health Organization, as a health organisation, come to a position that the safest option for women is the provision of abortion with less barriers as part of the health care system?

Dr. Ronald Johnson

I can start and then Dr. Ganatra can add to what I say. I would like to be very clear that the WHO does not promote abortion, just like we do not promote pregnancy. What we promote is the safety in each of those contexts. Perhaps Dr. Ganatra will respond to the health question.

Dr. Bela Ganatra

The committee has heard Dr. Johnson give the WHO's definition of health as a complete state of social well-being. Reproductive health needs are part and parcel of a woman's health needs during the course of her life. The need for an abortion is also part of reproductive health needs during the course of life for many women. As far as the WHO is concerned, it is a health issue and needs to be addressed just like any other health issue is addressed. Medical standards have to be talked about just as one would for pregnancy care or anything else.

Dr. Ronald Johnson

To put this in a historical context, unsafe abortion was identified by the WHO as a public health concern in 1967 and there was a world health assembly resolution signed by most if not all of the countries. It has been a huge problem over time. It is becoming less unsafe as Dr. Ganatra mentioned and as this paper indicated but it is a huge issue for women. The safety spans physical health, mental health and social well-being as well. It has not gone away and it will not go away.

I think the witnesses' clear points strengthen the points they are making. They come from the background of public health. I note that last week the WHO released figures showing 25.1 million abortions in the world are unsafe. We are talking, largely, in this section although not exclusively about first trimester abortions, which the witnesses said are very simple and they can be provided at primary care level on an outpatient basis. I agree with the witnesses. There was an article last week in The Guardian written by the head of obstetrics and gynaecology in Britain. The point was made that the service should be provided by nurses and midwives. Medication is prescribed in cases of missed miscarriages anyway. On the issue of access, which seems to me to be the key issue which we as a committee need to address, that approach would be one way in which the service could be made available and it would address overcoming some of the barriers. Do the witnesses have any comments on that or have they had any dialogue on the issue?

Deputy Daly is over time so I ask the witnesses to be very brief in their response.

Dr. Bela Ganatra

What Deputy Daly said is very much along what our guidelines also say.

Dr. Abigail Aiken

Deputy Daly is correct about the safety. I want to bring this up because botched abortions were mentioned. That statistic on Canada is for later gestations where sometimes people deliver a live baby, because that is what they have chosen to do because of the foetal anomaly, to give them time to spend with the baby before it expires naturally. Calling them botched abortions is very disrespectful and I just wanted to put the record straight.

I call Deputy Naughton. She has six minutes. I am very keen for people to keep to their allotted time because we have other witnesses coming in at 4 p.m.

Dr. Ganatra made an excellent presentation and I thank her very much for that. I accept that the figures cannot be broken down by country. Is there a disparity in regard to the maternal mortality rates in countries where abortion is freely available compared to countries where it is not freely available? Perhaps the question has already been answered in the case of Romania. Could Dr. Ganatra comment on the situation in general terms in regard to an estimate for what impact it would have on maternal mortality rates if abortion were freely available in Ireland? Are there other reasons implied in the figure we were given?

In a country where abortion is freely available are there any data on whether there is more screening in regard to minor disabilities and, if so, is a greater number of abortions sought thereafter?

Dr. Bela Ganatra

In terms of maternal mortality one thing to realise is that measuring the proportion of abortion deaths as a part of maternal deaths is not necessarily the best way to think about abortion safety, because it is relative to other causes of maternal deaths and abortion can be particularly unsafe but not contribute to a large proportion of maternal mortality or vice versa. We do look at case fatality rates and we have seen that case fatality rates, that is, the number of abortions that lead to death, are the highest in contexts where they have been most unsafe.

One also has to know that complications from unsafe abortion can occur but where health systems are good and treatment for complications is available death might be prevented so that one does not see that as a death but then again one has masked a problem that occurred. We have to be careful with the focus on deaths but that is why our focus is now shifting to the standards of care and the morbidity aspect, and not just focusing on the outcome of death for all health issues, not just for this one.

In terms of the question on screening, are there any data on that which we could look at?

Dr. Bela Ganatra

I do not have that at the moment.

I thank Deputy Naughton and call Senator Gavan. He has six minutes in total.

You will be pleased to hear, Chair, that I will not need six minutes.

That is good.

I have a couple of questions. I wish to get rid of a couple of myths that have been spun on one side of the debate.

Will someone on the panel, please, tell me what are the risks associated with abortion? Does it, for example, result in a higher risk of breast cancer or mental health problems or are these ill-informed myths? Would Dr. Aiken say there is a dereliction of State responsibility in Ireland in providing post-abortion services? In her report she states "the current Irish abortion law limits the information and support that Irish health care professionals can provide to women." Will she expand on this for us if she has time?

Dr. Ronald Johnson

As far as we know - this is on page 49 of the guidelines - there are no known risks for breast cancer, future reproduction or mental health. The risks are no greater for women who have an abortion than among the general population.

Dr. Abigail Aiken

Although the law in Ireland does allow health care professionals to treat post-abortion complications or provide counselling and allows the provision of information on travelling for an abortion, there is what my colleague has referred to as a chilling effect. The Senator will see in some of the quotes included in the packet that health care professionals do not feel comfortable or feel there is a risk in going too far because the law does not prescribe exactly what they can say. When it tries to legislate for what is really within good informed consent or between a doctor and a patient, it runs into trouble. That is why there is are medical oversight bodies to decide that rather than governments. It has been made very difficult for providers to do post-abortion services well because there is no continuity of care. If someone says he or she has carried out an abortion, he or she may not be telling everything. He or she may have done something that is illegal and does not feel he or she can say that. As someone quoted in the packet says, their first thought should not have been how they were going to lie. It interferes with what should be a good trusting relationship between a patient and a doctor, whether before or after an abortion.

I thank the delegates for their presentations and apologise for having to leave to vote. One of the most significant statements they have made is that they are coming from a public health perspective and not promoting abortion. I am very happy to hear that. What proportion of a health budget would Dr. Johnson say the cost of abortion services would be to the State from a public health perspective? I am not asking him to be prescriptive on the actual cost. From his experience, given that in this country we have a private health insurance model, how can we encourage or mandate health insurance companies to provide cover or a plan for women? Who, in his opinion, should oversee or inspect clinics? In this country the Health Information and Quality Authority oversees and inspects different parts of the health system. Who should do it if we change our model?

I thank the delegates for their excellent presentations which were breathtakingly interesting.

Dr. Ronald Johnson

In most countries oversight is by the Department or Ministry of Health. The WHO would be very willing to work with the Department of Health to help to develop the systems of supervision and oversight.

I cannot answer the question about costs. The cost of an abortion varies across the world from being free to $1,000. Women in New Zealand and the United Kingdom receive a free service. The cost of an illegal abortion can be astronomical. There are so many technicalities in estimating the cost for a particular system and we do not have the information necessary to process it, but we could certainly sit down and work with the committee on that issue.

What about inspections and quality control, if I can use that phrase?

Dr. Ronald Johnson

The Department of Health.

Dr. Bela Ganatra

Or professional medical societies which regulate all other clinical practices.

Dr. Ronald Johnson

There are different models in different countries.

Dr. Bela Ganatra

That is generally how it works in most places.

If we were to change our policy or laws to begin a new regime, how long would it take to put everything in place to allow the termination of pregnancies to take place?

Dr. Ronald Johnson

That is a tricky one because there is a culture of health care and service provision and, like all cultures, it is different. There has to be an enabling policy environment and people who are willing to implement the change. I do not know if there are such persons here, but that is the big question. If there are people here who are committed to implementing it, it should be easy. It is simple. Abortion is simple. Adding it to the health service would be very simple, but there have to be the personnel who are enthusiastic about doing it.

Dr. Aiken would know the cost of mifepristone and misoprostol.

If Dr. Aiken wishes to respond, she is welcome to do so.

Dr. Abigail Aiken

One thing to consider is that pregnancy care is extremely expensive and more expensive than abortion care. The price of mifepristone and misoprostol varies widely by country, but they are not expensive medications to manufacture and the price would depend on who was providing them.

Dr. Ronald Johnson

Misoprostol is a generic drug and very inexpensive - the price is cents per tablet Mifepristone is now also very inexpensive. It can be sourced in bulk for approximately $3.50 per tablet. There are models in the world in which the ministries of health procure it directly from the manufacturers. That is the cheapest model. As soon as it is run through the private sector, there are import taxes and a mark-up at approximately five places along the way. It should be and can be cheap, but it is not always.

I thank all of the delegates for coming. I do respect them. I have listened and learned. The focus, however, was on abortion and how to introduce it in Ireland.

Dr. Johnson has said that if we reduce the number of unwanted pregnancies, we can reduce the number of abortions. Dr. Aiken has said that when women leave clinics, they are helped with contraceptives. I believe in life and living. I have a little quote: "Enjoy the little things in life, for one day you may look back and realise they were big things". If I google the term "unwanted pregnancies", what comes up is information on abortion treatment in private clinics in Manchester which includes the words "call privately on your mobile", "book an appointment", "request a call back", "trained advisers", "services", "consultation" and "sterilisation". Moving down, the next thing I come across is "emergency contraceptives" which must be taken within 72 hours of unprotected sex in order to prevent an unplanned pregnancy. It is then indicated at what stage it should be done with tablets.

It feels as if abortion is being pushed into people's faces. Dr. Johnson has mentioned that safety is his priority. To me, having a baby is the safest way. Ireland is one of the safest countries to a have a baby. I have been getting a lot of flak for the past four weeks at these sessions, but I trust women. The most important people in my life are my wife and my family. I am trying to be honest. I do not believe in abortion. The first option should be to have the baby. What can we do in Ireland to try to educate people? To me, abortion should definitely be the last option for anybody. When people are looking for help, they have many means of communication. If a woman who does not want to be pregnant is looking for help, the first thing she will do is google and this will be pushed in her face. What can we do to give such people a far better option? I again emphasise that I trust women.

Dr. Abigail Aiken

I thank the Deputy and appreciate his opinion. I will say a couple of things in response to him.

Maternal mortality rates are very low in Ireland. The Deputy is right when he says Ireland has extremely good obstetric and maternity services. However, this presumes that people want to go through with pregnancies and end up giving birth to babies. That is great and there are excellent obstetric services here. The problem we are discussing involves people who are not in that position. The figures for them are not factored into the maternal mortality rate because they are able to go to England or use the Women on Web website. Ireland has a low maternal mortality rate which is great, but it really does not offer many options to those who are deciding what to do about their pregnancies.

One of the problems is that although there are many opinions in this room and Ireland on this issue, it is very difficult to legislate for opinions. Everyone has a different opinion. We came to present evidence to the committee in order that its members would learn more about the people who were relying on us to do something. It is not so much about our individual opinions but more about those who need help from the committee as it decides what to do. Although pregnancy is nice and joyful for many, it carries many physical and anatomical risks. It is an awful lot to expect a woman to do with her body, especially if it is something she does not want to do and would choose not to do. While pregnancy has been made very safe by the excellent obstetric services available in Ireland, it has to be recognised that it is not inherently very safe.

That concludes our questions. I thank the delegates for their attendance. They have given us excellent information and I thank them for responding to all of the questions asked by members. We really appreciate the effort they have made in travelling to this country to be here.

Sitting suspended at 4.25 p.m. and resumed at 4.35 p.m.