Crisis Pregnancy and Primary Care: Irish College of General Practitioners

I welcome members and viewers who may be watching on Oireachtas TV to this afternoon's meeting of the committee. At the risk of being repetitive, 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. On behalf of the committee I extend a warm welcome to our witnesses from the Irish College of General Practitioners, Dr. Brendan O'Shea, director of the postgraduate resource centre, and Dr. Karena Hanley, national director of GP training. We had planned to have Ms Janice Donlon from the HSE's sexual health and crisis pregnancy programme to present to us this afternoon, but due to illness she cannot, unfortunately, be here. We hope to reschedule her attendance for next week but we will have to wait and see.

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. O'Shea to make his presentation. We have assigned ten minutes for the submission.

Dr. Brendan O'Shea

On behalf of the Irish College of General Practitioners, I thank the committee very much for inviting us to make a submission and assist in the difficult, important and complex task on which the committee has embarked. The Irish College of General Practitioners wishes the committee the very best in the successful completion of its job. I am accompanied by Dr. Karena Hanley and we have been requested to present the Irish general practice perspective on crisis pregnancy focusing on the health of the woman, with no distinction being drawn between physical and mental health in the context of the eighth amendment of the Constitution.

As family doctors, general practitioners, GPs, are familiar with the reproductive health-care challenges facing Irish women. Irish GPs provide antenatal care to Irish women. For the majority of pregnant women, antenatal care and support before 20 weeks' gestation is provided by GPs alone. After this date, GPs provide shared antenatal care with hospital colleagues in obstetrics and midwifery. When a pregnancy is unwanted, Irish GPs support and provide evidence-based care for women through this difficult experience, which will be articulated in this submission. Irish GPs also provide high-quality contraception health care to Irish women and men. Thus, the Irish College of General Practitioners, ICGP, is well placed to understand the concerns and fears facing Irish women regarding reproductive health care.

The ICGP has been asked by the committee to focus on the health of the woman, with no distinction being drawn between physical and mental health, in the context of the eighth amendment of the Irish Constitution. The World Health Organisation definition of "health" since 1948 states:

Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.

Evidence-based management of crisis pregnancy, with a focus on the effects on the health of the woman, is included in this evidence-based submission.

Dr. Karena Hanley

A crisis pregnancy is a pregnancy which is neither planned nor desired by the woman concerned and which represents a personal crisis for her. Crisis pregnancy can affect women of any reproductive age, social group or area of the country. Crisis pregnancies are common and constitute up to 13% of all pregnancies. While most of these pregnancies result in parenthood, approximately 14% end in miscarriage, 21% with abortion and 1% with adoption. It remains the case that more than 3,000 women travel from this country every year to obtain abortion elsewhere. Of concern is the rising number of more than 1,000 each year who obtain abortifacient pills online and administer them personally and without medical supervision.

How do we prevent crisis pregnancy? Effective contraception is key. GPs try to be proactive in the provision of available contraception to all women who are sexually active. Our colleagues in the HSE sexual health and crisis pregnancy programme support a range of educational programmes, research, counselling and medical services. The Irish Family Planning Association also provides excellent contraceptive care. Despite all of the efforts of the Government, educational initiatives and services, crisis pregnancy cannot always be prevented. Most GPs witness and take care of crisis pregnancy on a common basis. We know that abortion rates are lowest in health systems where contraceptive services are most readily available. As the committee heard yesterday, however, there are still barriers to contraceptive services in Ireland, in particular the cost and misplaced concerns around confidentiality, especially among younger women. The eighth amendment does not actually impact upon contraception and emergency contraception management for Irish women.

Dr. Brendan O'Shea

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

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

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

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

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

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

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

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

Dr. Karena Hanley

I will talk about the impact on the health of the woman. I will start with travel. Reflecting on the vignette, one can understand the psychological cost to that woman, the stress, the loneliness and the psychological burden of travelling to procure an abortion. There is also a physical risk to women who, as they travel, do not have access to post-abortion services that are available in the country where it was performed. There are also logistical difficulties and financial costs. Crisis pregnancy can have a profound effect on the woman's partner and wider family, but for this presentation we have focused on the woman only. The logistics of travel also mean that women travelling from this country tend to have later abortions and a higher proportion of surgical interventions. There are also women who cannot travel, including those who are disabled, without financial means, socially isolated and asylum seekers, who cannot leave this country for abortion.

We would like to bring to the committee's attention the harm that can be done by inaccurate information from unlicensed, unaccredited counselling agents, who sometimes give distressing and incorrect information.

I will address the Protection of Life During Pregnancy Act. It allows for lawful abortion when there is a real and substantial risk to the life of the mother. Most of the 25 terminations conducted under this legislation are performed by our obstetric colleagues and GPs are not involved, but we are in involved where the risk to life is a risk of suicide. The clinical pathway in this context requires referral from the GP to local general psychiatry services. Two psychiatrists and one obstetrician then need to agree that an abortion is lawful under that Act. Very few cases have been performed under this arrangement and the experience of Miss Y needs to be considered. This arrangement tends to lead to delays in accessing termination of the pregnancy and, if the second psychiatrist is outside the location, this adds to the difficulty. Criminalisation needs to be considered. This relates to the increasing numbers of women who procure abortion pills online. They may be criminalised with the potential of a 14-year prison sentence. This may prevent them from reporting to Irish doctors, which could seriously impact their health.

Dr. Brendan O'Shea

To summarise and conclude, the ICGP is thankful that the Joint Committee on the Eighth Amendment of the Constitution invites our input. Abortion is a divisive, difficult and polarising topic. Irish general practitioners have debated this theme internally within college, and similar to the broader population, we have witnessed conflicting opinions, concerns and beliefs among our own group. The constitutional criminalisation of abortion in Ireland has made this a more difficult issue to discuss in public. It has also made a significantly more difficult issue when attempting to provide care in the care setting. However, crisis pregnancy is a large-scale reality facing Irish women. Many Irish women choose to access abortion services, which we must deal with more effectively as a society. The eighth amendment clearly raises difficult ethical and moral issues for the public and health care providers. We hope that the ICGP has informed on how crisis pregnancy can impact the health of the woman, and how GPs currently care for such women. We outlined the impact on the health of women, as requested by the committee. We will not recommend solutions for that is for this committee to decide.

I thank Dr. Hanley and Dr. O'Shea. We do not have lead questioners today. I will take indications from everybody. I hope that we might proceed on the basis that people ask questions for two minutes and allow time for a response because it was the inverse yesterday and just did not work. I will go with that today and will cut members off at approximately two minutes. I call Deputy Jan O'Sullivan.

I thank the witnesses for their presentations. It is really useful to have the perspective of GPs because of the relationship they have with patients and also, as Dr. O'Shea said, the fact that in the early months, it is primarily the GP that deals with the issue.

Dr. Hanley spoke about rogue agencies. Can she say how big an issue this is? Is she aware of any advice being given? There is no process of referral. One can give a patient a chart but one cannot engage with a health provider in another jurisdiction. How much difficulty does that cause for the health of the woman concerned?

Dr. Hanley said abortion rates are lowest where contraception is most available. Are there still barriers to accessing contraception in Ireland? Would reducing barriers and allowing more effective access to contraception be more effective in reducing the number of abortions than allowing the issue to be a criminal one, as we do now? I know Dr. Hanley does not want to make a direct statement on the eighth amendment but she certainly implied that it makes it very difficult for GPs to deal with their patients adequately.

Dr. Karena Hanley

The number of rogue agencies can vary depending on which part of the country one lives in. Perhaps the HSE can give more evidence to the committee on this. On the website positiveoptions.ie there is a tab which states "Don't be manipulated", which is there because it has been the experience of women in crisis pregnancy in this country, and continues to be in a small number of locations, that agencies purporting to be counsellors in crisis pregnancy have a hidden agenda and seek to heavily influence the decision of the mother and the outcome of the pregnancy.

Dr. Brendan O'Shea

There is an impression that people with a crisis pregnancy are encouraged to take their time to make their mind up but delay carries a medical risk in this particular care setting.

Is this a more widespread issue than we might have been led to believe?

Dr. Brendan O'Shea

It is difficult to objectively quantify it but we believe this is a feature of the care environment. We are concerned about this and we believe our concern is shared by our colleagues in the HSE crisis pregnancy agency. The Deputy asked an excellent question about referral. We have a classic Irish solution to an Irish problem. When my parents were in practice it was all about the oral contraceptive pill, which we were allowed to prescribe for cycle regulation. If a woman had the slightest smidgen of an irregular cycle she was all right. Later on we were allowed to make condoms available to people as long as they were married. Now we can talk about termination but we are not allowed to make a referral. From a medical perspective, there is objective evidence that abortion is a relatively safe medical procedure but the experience to which we subject women who travel for abortion is something else and it is traumatic to consider any sister, mother or daughter travelling to a UK abortion clinic in these circumstances. They are sick with the symptoms of early pregnancy and they feel uncertainty about what they are embarking on, not to mention the cost, etc. Many of us believe it makes far more sense for referrals to be done in a medical fashion, or for other solutions to be examined.

Dr. Karena Hanley

I was asked if there were still barriers to accessing contraception. The barriers have diminished exponentially in the past 20 years and this is probably why the numbers travelling to other jurisdictions have dropped. There are still too many myths out there and too many young women think the contraceptive pill makes them put on weight. Too many rely on emergency contraception. The failure rate for emergency contraception used to be one in 20 but this is improving and there are good initiatives, such as the website spunout.ie, which does very good health promotion and has lots of information.

Dr. Brendan O'Shea

We concur with the observations of our colleagues in the WHO who said yesterday that there was a significant difference between our health system and the NHS in terms of the availability of contraception. Clear steps, both educational and resourcing, can be taken to improve this. There are not enough general practitioners and we are particularly short of practice nurses, which has ramifications for a lot of other areas including that of reproductive health.

Dr. Hanley referred to influencing patients. For the avoidance of confusion, can she expand on what she meant by that?

Dr. Karena Hanley

What was the context?

It was in the context of rogue agencies.

Dr. Karena Hanley

There are some people who purport to be independent counselling organisations and who would show distressing videos, delay the result of a pregnancy test or say they wish to meet the woman in a car park or a hotel lobby. This is all on positiveoptions.ie. It is not very common but positiveoptions.ie warns against this.

I felt it was important to clarify that point.

Like Deputy Jan O'Sullivan, I believe the fact the witnesses deal with women in the early stages of pregnancy means they are the women's sole carers. This is the time when most abortions take place so their testimony is very important. The circumstances outlined by the witnesses in their contribution tally with the evidence we heard yesterday. The reasons women choose to have an abortion do not coincide with some of the reasons often supposed, such as when rape is involved or in cases of fatal foetal abnormalities. If this committee was to advocate reasons-based access to abortion do the witnesses believe it would meet the need of women to access abortion services? In order to protect the health of women, would it not be better to allow early availability of abortion, that is, in the first 12 weeks, with no restriction? Would that meet the needs of women who currently present to doctors for diverse reasons? What is the best way for them to get access to abortion to improve their health?

Dr. Brendan O'Shea

We are here as representatives of the college and have been asked to brief the committee on issues relating to the health of women. We are not here to offer solutions but we can refer, with some degree of knowledge and expertise, to practices in adjoining health systems. We are particularly sensitive to risks to the health of a woman and this is paramount in the mind of any general practitioner or practice nurse in the course of a consultation. The risk becomes higher the later an abortion is carried out but in other systems medical abortions within 12 weeks are carried out on a system scale. From a purely medical perspective, and purely with respect to the health of the woman, this reduces the medical risk.

Dr. O'Shea may have seen the report in the papers last week from the head of the Royal College of Obstetricians and Gynaecologists in the UK.

She recommended that nurses and midwives should be able to administer the abortion pill. I presume in an Irish context and in light of what the witness said about the shortage of nurses, it would make perfect sense for somebody to go to a GP. Given that the relationship between a woman and her doctor is altered by potential criminalisation and barriers, it would be best if her doctor could provide the medical treatment the woman would probably access online without admitting it anyway. Is that a system that would work?

Dr. Brendan O'Shea

That is a system that could work.

I know the witnesses are here to speak purely from a health perspective. Would it minimise trauma and travel? We were given overwhelming evidence yesterday on the safety of the abortion pill. From a health perspective, it would be a way to minimise some of the harm being done at present.

Dr. Brendan O'Shea

As general practitioners we are concerned and deeply interested in our role in whatever way this develops as a societal response to the issue. We feel strongly there are incidents where general practitioners are required to be particularly involved, especially should complications arise. There is a need for a registered medical practitioner to be involved at that point. It is evident from our study of systems abroad that different configurations whereby these services can be made available are in place and acceptable. These can be compared with the current set of circumstances applying in Ireland. We know, for example, from British figures that when Irish women have terminations in the United Kingdom, they tend to be several weeks later, almost certainly reflecting the process in place for the women travelling for abortions. It is relatively straightforward to draw conclusions on the basis of medical risk.

Are there any other circumstances where the relationship between a patient and doctor is interfered with by the State or where the clinician's hands are tied in the manner in which treatment of pregnant women is?

Dr. Brendan O'Shea

There is nothing like this.

I appreciate the Deputy staying within her time.

I thank the witnesses for coming in as when somebody is pregnant, the doctors are working at the coalface. They are the first port of call. Doctors operate within a legal framework of an equal right to life rather than a right to health. Doctors are supposed to be looking after the health of a patient, which is incredibly difficult.

We might consider matters such as gestational limits. In Canada, for example, this is dealt with exclusively as a health care matter between a woman and her doctor. There are no prescribed limits, as far as I know. I presume the witnesses are familiar with that system. Will they elaborate on how that works, from what they know?

Dr. Karena Hanley

Neither of us could confess to being familiar with exactly what the Deputy is talking about. Generally, the principle is the earlier in pregnancy that a termination occurs, the safer it is and the easier it is for the mother. It would clearly be much less traumatic. The general principle that the earlier this can be accommodated, the better, is really important to hold dear. We are not really qualified to comment further.

That is fine. I am probably putting the witnesses on the spot there.

Dr. Brendan O'Shea

There is an international evidence base that may be accessed describing how this process is delivered or provided in other health systems. It is a very well written area of research. The data are available.

What would be the effect of medical ethics in addition to the legal framework? If, for example, the eighth amendment to the Constitution was deleted next year and we had a transition period, how would medical ethics deal with this issue? Would doctors still be required to deal with whatever law is on the Statute Book, would there be an interregnum or what would happen?

Dr. Karena Hanley

It might help if I clarified the current Medical Council ethical guidelines and we can see where that brings us. The most recent edition of the Medical Council guidelines are from 2016 and they state they reflect the legal position on abortion; it is assumed they always will effect the legal position on abortion. The guidelines advise of the duty to provide care, support and follow-up services for women, no matter what choices the women have made. It specifically states this includes those who have had an abortion abroad. It also states a doctor has an ethical obligation not to allow his or her personal moral standards to influence treatment of patients. It goes on to state that where a doctor has a conscientious objection to a course of action, the doctor must explain this to the patient and must make available the names of other doctors to the patient so the service can be provided. I imagine the ethical guidelines will adapt to changes in a similar fashion.

Some provision is given for other medical services abroad and the likes of the National Treatment Purchase Fund would be a case in point of arrangements being made in this respect. I presume in that scenario there would be ongoing continuity of care. What we are discussing is really at odds with how medical care is carried out.

Dr. Brendan O'Shea

It is at present. To step out of the abortion discussion, all general practitioners have experience of the National Treatment Purchase Fund and in key respects it is a useful and important part of care provided. There certainly are aspects of it where continuity of care is often in question. Care in those cases is taken from a standard clinical pathway and provided in a different hospital.

I thank the witnesses for the presentation. Is it their opinion that the current legal position in this country, with the eighth amendment to the Constitution and the Protection of Life During Pregnancy Act 2013, presents a threat to the lives and health of Irish women?

Dr. Brendan O'Shea

Yes.

The witness has already answered one of my questions. I was going to ask how many additional weeks, on average, are evident in gestation before termination because services are not available here and women must travel. I believe they said it was "several" weeks.

Dr. Brendan O'Shea

A precise period in this regard would be in the order of one to two weeks. That is significant in this context.

Of course. Will the witnesses elaborate a little on their experience when they tell a woman presenting to their practice in a crisis pregnancy that she cannot access services here and a doctor cannot help her to access services elsewhere? Does this add to stress in the case and compound the matter?

Dr. Karena Hanley

It is important in dealing with a woman presenting with a crisis situation to be absolutely non-judgmental and to allow the woman space to consider all options. One must ensure she has considered all options and there is a legal obligation in that regard. It is not the case that we can ever say "I cannot help you access services elsewhere" because we are allowed to provide information, which can be very useful to the woman. We cannot write a referral letter or tell the woman what it might cost to access those services elsewhere but we can direct the woman where to find that information. However, there are certain cases where this information would be of no use to the woman because, for one reason or another, she cannot travel. These are clearly very distressful situations to deal with.

Will the witnesses elaborate on the clinical risks to a pregnant woman having to travel? What additional risks does that pose to a woman in comparison with being able to stay here?

Dr. Karena Hanley

The risks involved in a termination of pregnancy vary according to the gestational age of the termination and the procedure, whether it is a medical abortion or a surgical intervention. The risk of bleed, which is the biggest risk to a woman, is in the order of one per thousand, rising up to four per thousand, depending on the gestational age. It is also higher where there has been a surgical intervention. There is also a risk of uterine rupture where there has been a surgical intervention, again in the order of one per thousand to four per thousand. The other serious risk to the woman is infection, which, whether it is a medical termination or a surgical intervention, is in the order of 2% to 2.5%. Those are the risks of serious adverse effects of abortion.

Dr. Brendan O'Shea

To put that in the context of the Deputy's question, which concerned how these risks are amplified by the requirement to travel, they are amplified because travelling results in delay, which increases the probability that any of these complications might happen. There are also peculiar risks relating to travel, including the need to organise a journey. We have to see this in a social context. Often a crisis pregnancy is a secretive thing. It is not easy sometimes for the woman to collaborate with the people who normally help her because they do not know about it or she does not want them to know about it. There is the anxiety and stress associated with trying to find money to organise the travel. It is often a real issue for these women. If they have children at home, arrangements have to be put in place. It becomes a huge stressor to organise all of that in an aura of secrecy, criminalisation and guilt. The work of organising a journey like that in the situation of early pregnancy, which is characterised by tiredness, fatigue, nausea, stress, anxiety and uncertainty, adds a significant additional psychological risk which makes it extremely difficult for women, who are sisters, mothers, aunts and wives of ours.

The witnesses spoke about the aftercare services and counselling available in the UK. Can they elaborate on what services are available in the UK to citizens? What services are available here, and how much do they cost?

Dr. Karena Hanley

The point I was making was that they do not have any access to the aftercare services when they are travelling. In fact, the aftercare services are quite good in this country. There is a website called abortionaftercare.ie, which is supplied by the HSE and which provides access to some information, and the Irish College of General Practitioners, ICGP, guide on crisis pregnancy has a chapter on aftercare post-abortion which gives very good information on how to deal with all complications, psychological support for the woman and how to address contraception to prevent future crisis pregnancies. Once the access has been made very clear to the woman, the framework of aftercare is probably similar in both jurisdictions.

Of the 5,000 to 6,000 identified how many are actually presenting? Is it possible to say how many are presenting for aftercare of some sort, with GPs or otherwise?

Dr. Karena Hanley

Is the Chairman referring to the 5,000 or 6,000 who access medical abortion?

Both, I suppose.

Dr. Karena Hanley

We understand that around 10% of GPs in the country have had experience of dealing with women. We also think that about 15% of women who avail of medical abortion will be in contact with medical services afterwards.

The majority do not.

Dr. Karena Hanley

The vast majority do not.

I thank the witnesses for coming before the committee today and for their evidence. It is very helpful.

With reference to the point made about 10% of women accessing aftercare, in the event of that figure going up, even to 100%, do we have the staff and resources, and do GPs have the skills and training necessary to be able to provide that counselling and support? Is there specific training, and do all GPs avail of that? Is it considered part of general care?

Yesterday we heard from Professor Malone, who was very clear about what does and does not constitute a full range of health care for women. He was clear that he felt unable to provide what he would consider to be the full range without access to terminations. Do the witnesses share that view? Is there a psychological impact on the GPs themselves who cannot refer for the full range of services? It is important to note that doctors do not get into the business of treating women without wanting to make a positive difference.

In the event that a woman is on a medical card and the GP to whom her medical card is assigned has a conscientious objection to treating her, whether that is post-abortion care or any care related to a termination and she has to transfer to another practice, that can take a long time. Is there any provision for that? Have the witnesses encountered that? Is there anything that can be done to make it any easier?

Dr. Karena Hanley

It is important to understand that it would be highly unlikely that a situation would ever arise that 100% of women would need to access aftercare post-abortion because it is a safe procedure and goes very smoothly in the vast majority of situations. I cannot see a situation where there would be a significant rise in the proportion of those requiring aftercare.

In terms of specific training, we have a number of items of our ICGP training curriculum in dealing with crisis pregnancy, the requirement to follow the ethical council guidelines in knowing the legislation and in dealing with the absolute need to support the woman in her choice. In terms of any further training that might be needed, the ICGP is very well placed to adapt to this. We have an extremely active women's health division within the ICGP. The guide on crisis pregnancy was recently updated. It is updated usually every three to five years. The response is already ingrained within our organisation.

To be clear, are those courses compulsory or optional?

Dr. Karena Hanley

When the Protection of Life in Pregnancy Act 2013 came in, the ICGP responded and put together an information pack for all its members. We have a track record of being able to respond rapidly.

Dr. Brendan O'Shea

I would strongly concur with my colleague, as I always do. There is no doubt, from the perspective of the ICGP, that members of the college do have the necessary skills. A question mark lies over our total capacity, but as I said earlier, this does not particularly relate to capacity in this area but rather all capacity in general practice. The country is quite short of general practitioners and very short of practice nurses. It is a capacity rather than skills problem. It is a relatively straightforward deficit to correct in the context of whole system management.

On the question of whether there is an impact on the GP concerned, we understand that at times this is actually quite stressful for individual GPs. That is reflected in our system of peer-reviewed support, which is largely delivered through the CME network and is run by a series of tutors. It involves a majority of GPs reflecting on a monthly basis. Challenging and problem case management is something that we often discuss, and certainly this area of care is often reflected in those discussions.

Individually, general practitioners can be quite challenged and exercised, and occasionally, almost wounded by the experience. In particular, there are certain situations that all of us who have been in practice for years have come across. The issue of late terminations can be extremely stressful and difficult. General practitioners, by and large, are resilient people and we get on with things as we must.

With respect to the issue of a practitioner who is caring for a person who is eligible for a medical card and who is also a conscientious objector, in theory that could be a problem but in practice we do not see that it is an issue. I suppose it is all right for us to say that in the Irish College of General Practitioners, but in good faith we do not see or understand that this has been a problem for our patients. People rapidly understand the difficulty and gravity of this matter and they move quickly to take appropriate steps. We hope that we are correct in that regard.

Dr. Karena Hanley

There is a mechanism within the medical card provision of services for inter-GP referral.

Dr. Brendan O'Shea

Yes.

It takes time and that is the issue.

Dr. Karena Hanley

It should not take time. A telephone call should suffice.

Dr. Karena Hanley

There is at least the ability to respond. There still is same-day access in most of the country. Despite all of the problems, we have not reached waiting lists of two and three weeks in general practice yet, and I hope we never do. I would hope it would not take time.

Dr. Brendan O'Shea

In practical terms, often it can be organised within a practice of two, three or four general practitioners. I do not think it is real problem but it is good to give it consideration.

I thank both of the witnesses for their presentations. I have two questions that touch on and builds on the kind of issues that have already been raised. I would like these matters to be teased out a little bit more.

It has been acknowledged that rogue agencies exist. How can we move forward to set a standard for crisis pregnancy counselling? Rogue agencies have done a disservice to the country in terms of having information providers that are unbiased and give positive experiences. Rogue agencies have left women in a fearful state. Women are afraid to reach out and ask for help and advice. We must ensure that women get the real advice and counselling that they deserve in that situation. I hope that the delegation can provide a description of how GPs are trained to give non-directive and impartial information to women. Please explain how the GP experience and training could be expanded to inform a national regulatory framework for pregnancy counselling to prevent rogue agencies from manipulating women.

In his presentation Dr. O'Shea described the approach taken by GPs when their patients experience a crisis pregnancy. I was heartened by the description. The approach is positive, professional and compassionate. I am concerned, despite the description of best practice, that does not mean that every woman gets support of such high quality from her GP. Based on anecdotal evidence that I have heard over the years I want to know how a best-practice model can be imbedded into the national GP network. How can we monitor whether the model has been adhered to? Is there a mechanism in place to monitor what women experience when they approach their GP with a crisis pregnancy?

Dr. Karena Hanley

It is not our position to comment on rogue agencies and I might see if Dr. O'Shea wants to reply. I want to talk about counselling in crisis pregnancy. We have clear guidelines for such counselling. Our published literature is available to everyone on the ICGP website, not just members.

In terms of counselling, the three main goals of the process are as follows. First, establish rapport and gain the trust of the woman in crisis. Second, help her formulate a clear definition of the problem, which can be very interesting. Sometimes perspective can change when the matter is talked through, which is important to note. Third, enable her to establish goals for the management and resolution of the crisis. Our publication goes on to describe how one gives the woman space, and one gives her information about all of the alternatives that are available. There is a list of websites at the back of the publication where a lot more information can be gathered. One gives her the opportunity to explore the implications of each of the options. We give the woman the opportunity to assess her feelings, wishes and circumstances, and also further supports. Often one will have use of the website. IT development in general practice is very well advanced in Ireland and most of us will be able to show a woman where to go for assistance on the website.

In terms of how the best-practice model can be more uniformly distributed, that is always a challenge of medical education. There are multi-factoral ways in which we handle this matter in all areas. It is through our monthly publication forum, email shots and elearning platforms. All GPs have a requirement to gather continual professional development points. For example, the reading of our guide can be recorded as CPD points. There are ways. If it is felt that there is a need to promote this area then the college is in a very good position to do so.

Does Dr. O'Shea wish to answer any of the other questions?

Dr. Brendan O'Shea

Senator Ruane asked the very important question of how can we know whether every woman and her partner gets the best care in these circumstances. It is not all right to have fuzzy nice thoughts about that. It is an important question but, to some extent, it is a difficult question to answer with a high level of satisfaction. In general terms the considerations are as follows. We do always pay attention in our activities and focus in on when patients do not get best care in a variety of different care settings. This is a special care setting and it has got an additional complexity around it but it is part of what we do in the college. Quality is built into our key core message and it is the foundation message of the college.

We do understand that patients get suboptimal care if the doctor is unwell so we have an active health and practice programme, run through the ICGP, and have done so for many years. The programme is innovative. We do look to the health of general practitioners to make sure that they are well. If the GP is stressed or anxious he or she is more likely to be peremptory, dismissive, not in good form or otherwise receptive. That is one plank that protects patients.

We have features of practice. We have a practice management programme where patient feedback is built in. As part of that we encourage general practitioners and advise them, as part of good practice, to solicit and ask for feedback from their patients. We recognise that those in this patient group are especially vulnerable. It is difficult to conduct themselves as enfranchised consumers given the experience that they going through. Simple feedback on its own almost certainly is not enough. In the college, during the past year, we have formally sought to ascertain the additional ways that we can have patients or, really, people involved in our internal college processes. That is an area that has been highlighted by the college's board. Again, we hope that women and their partners who have gone through this experience may find a voice within college in terms of that. It is important for the integrity of the college.

There are other pieces that are relevant. Again, in all areas of care we are required to conduct practice audit. Certainly, any general practitioner or practice could choose to select audit activity around this area of care. There is a variety of mechanisms but none of is are mandatory or absolutely required. We would hope, given the variety of different options to safeguard patient well-being, that this group of women, despite the criminalisation of abortion, does not particularly get the thin edge of the wedge from the service that we provide.

I thank both witnesses for coming here today. My questions will follow on from what has been said by other speakers.

Is there any other aspect of health care that GPs deal in where they cannot refer properly? As the delegation has outlined, GPs do not have to look at the Constitution for any other aspect. The presentation contained a case study. What about a woman who has a clotting disorder but is otherwise fit and healthy? Obviously, a relatively simple, safe procedure such as a medically induced abortion or surgical abortion in the early stages would then have an added level of complexity. I ask the witnesses, as medical people, to tease out the matter. Can they explain how the barrier to GPs being unable to refer and send a woman carrying a photocopied chart under her arm that could be left on a plane affects such a case? People often go to their doctors with something on their minds but completely forget to say what is wrong with them due to the stress of the situation.

The process of teasing out information may be affected and the information may not be disseminated properly to the practitioner abroad, for whatever reason. I am not referring to suicide but rather to people with particular mental health needs.

As medical people, how do the witnesses feel about sending somebody on complex drugs for schizophrenia or borderline personality disorder, for example, off on their own on a plane or a boat? In those circumstances, what are the challenges for the witnesses professionally? Will they tease some of those issues out? Another issue concerns women with reduced immunity because of autoimmune diseases or who are on steroids, with the added risk of infection as a result.

We will allow the witnesses to answer those questions and if we have time the Deputy may ask some more.

Dr. Brendan O'Shea

Presumably because Deputy O'Connell has a strong professional health care background she knows all the buttons to press on our side. It is unique. One is nearly tempted to go back to the phrase used by that other parliamentarian - "grotesque, unbelievable, bizarre and unprecedented". There is no other situation in health care where we are not allowed to make a referral. When one considers the average patient - whoever that is - such as a 32-year-old, fit, healthy, adult woman, arguably the risk and level of complexity is quite low. However, we all know in practice that, given the complexity, unusual situations are quite common. The Deputy has outlined them all and has answered the question. It adds enormously to the uncertainty in these circumstances. These are the cases that keep us awake at night. They are the cases we feel vulnerable about. They are the cases where criminalisation looms large in the consultation for the practitioner. It is ironic that in 2017 the Irish State is only now finally rolling out electronic referrals to a whole range of services in the public system. We are not able to make a paper referral for this particular service. We are in a very difficult situation in primary care as matters stand on the eighth amendment.

I assume, in light of Dr. O'Shea's previous comments, the existence of the Protection of Life During Pregnancy Act, the presence of the eighth amendment to the Constitution and all of the issues I have just discussed, that I could sum up the situation by saying they are bad for women's health in Ireland. Could I say that?

Dr. Brendan O'Shea

Yes.

I thank the Deputy for her brevity.

I thank the witnesses for their presentations. I want to ask a number of questions. If a woman in one of the witnesses' surgeries decides on an abortion, have the witnesses ever told them it is illegal and they cannot have an abortion in this country? Has that woman ever said, "Okay, I won't have an abortion then"?

Dr. Brendan O'Shea

We are here as representatives of the Irish College of General Practitioners. We feel it is not appropriate for us to answer a question about our personal practice.

What I meant was, if a doctor says that to a woman, is it likely to put a woman off having an abortion? We regularly hear it argued in Ireland that the eighth amendment stops people having abortions.

Dr. Karena Hanley

We are legally obliged to address all options in a non-judgmental manner. To act in the way suggested by the Deputy would be poor practice and is not something the college supports. The college supports supporting the woman's choice in a non-judgmental manner and we are quite clear on that.

The point I was getting at is whether the witnesses think the fact it is illegal has ever stopped a woman from having an abortion.

I will move on. If a woman tells Dr. O'Shea or Dr. Hanley that she does not have the money to travel but has made up her mind to have an abortion, are they allowed to say anything about the availability of medical abortion pills which would save her that journey?

Dr. Karena Hanley

We are actually uncertain about that. It is legislatively a grey area at this point in time.

If such a woman is leaving the surgery in poverty or is in an abusive relationship, are there things she may do to try to end the pregnancy? Are the witnesses aware of such situations?

Dr. Brendan O'Shea

We are aware of those situations and in general terms when one is looking at a very restrictive legal framework, as we are in this country, it creates a risk that people will carry out actions that are injurious to their health with a view to terminating the pregnancy themselves.

The example the witness gave is actually a typical situation. We had a presentation yesterday from Dr. Abigail Aiken about the use of abortion pills and the studies she has done on woman. The example was given of Sandra, who is 38 and has three children. A lot of people think it is women who have never had a child who tend to have abortions. The example the witness gave is typical. Two thirds of women who used abortion pills have children already and are in their 30s. Are the witnesses familiar with the study that was mentioned yesterday? They mentioned the use of abortion pills but there has been an update on that figure. A study by the University of Kent estimated that 3,000 women contact two sites so the figure is probably much higher than one thinks. It could be five women a day.

I want to ask the witnesses about the survey of doctors' attitudes that they mentioned in their presentation. They say 10% of GPs believe abortion should never be allowed, which is probably similar to the figure among the general population. They say 51% believe it should be available to all women and 25% believe it should be allowed in some circumstances.

Dr. Brendan O'Shea

On restricted grounds.

That means about 76% of GPs probably believe it should be available to some or all women. That study was done in September 2012. Is there anything more up to date? The study predates the death of Savita Halappanavar.

Dr. Karena Hanley

That was the first study of this nature performed in Ireland and it has not been repeated since. Whether those figures have changed is open to conjecture.

Following on from Senator Ruane's point about what would ideally happen in a surgery, I have been in surgeries and I can see how, if a doctor is under pressure with a lot of people sitting outside waiting, the scenario might not be as ideal as the one outlined. GPs are instructed to give non-directive advice but if a GP is opposed to abortion is he or she seriously going to have it as an option?

Dr. Karena Hanley

They have an ethical responsibility. A doctor has an ethical obligation not to allow his or her personal moral standards influence the treatment of a patient. If a doctor has strong views and is a conscientious objector, he or she must explain that to the patient and must make the names of other doctors available. That is very clear guidance from the Medical Council.

I thank the witnesses for their presentation. Many of the questions have been answered at this stage but I want to hone in on one area. We have spoken a lot about the impact on woman of having to travel. The witnesses mentioned women who cannot travel for various reasons. I want to ask them about that because I cannot imagine how difficult it must be for a doctor and also for the patients. Will the witnesses expand on what impact it has on patients who have asked for a termination but cannot travel? How does a doctor deal with that?

Dr. Brendan O'Shea

We understand that most of the time in those circumstances the pregnancy is continued with as an unplanned pregnancy and proceeds to parenthood. We understand that will have a range of consequences on the wellness of the woman and an impact on her family. We can describe those in detail. It is a cause of concern. In the situation the Senator describes, it is the most likely outcome. There is an understanding that poorly regulated fertility is a significant contributor to poverty and poverty in turn is associated with a variety of adverse health effects. That is the main part of the answer to the Senator's question.

One of the witnesses referred to that situation being highly distressing.

Dr. Brendan O'Shea

It is highly distressing. Many practitioners believe one should stand back and look at the entire set of circumstances. A practitioner who feels responsible for his or her practice may consider whether there has been a failure of contraception and why that has happened. It is a highly unsatisfactory situation.

I thank Drs. O'Shea and Hanley for their attendance. It is extraordinary that there has been no mention of women who regret having an abortion in any of the evidence presented to the committee. There is no doubt that some women who travelled for an abortion regret their decision and that should be central to this debate. Groups such as Women Hurt, which comprises women who regret having an abortion, have very serious stories to tell. There is a regrettable tendency to shut their voices out of the debate but members can only benefit from hearing of their experiences. Those women get very upset when people suggest they do not exist. They do exist. It annoys me that Dr. O'Shea told the story of one woman but nobody has told the committee the stories of women who regret having an abortion.

Dr. Brendan O'Shea

The Deputy has raised the very important question of women who regret having had an abortion. From the perspective of general practice, we appreciate that whether or not to have greater availability of abortion in this country is a very important issue. Many general practitioners believe the issue of contraception is arguably even more important and a critical part of the long-term solution. I concur with Deputy Fitzpatrick that the stories of women who regret having had an abortion are quite important.

There is an evidence base on this issue, in particular a study conducted in the United States called the turnaway study, which looked at psychological sequelae in women who had or were denied a termination. Its methodology is a little complex. Two sample groups of women were recruited into the study from a variety of centres across the United States, and that has to be interpreted accordingly. The women took part in the study close to the time of their making a decision on a termination. Some proceeded to have a termination and others were denied a termination on grounds. They were then followed for a period of five to seven years and the psychological impact of their experience was measured and examined. That is not the exact issue raised by the Deputy but it is quite close to it. The turnaway study found that the level of psychological symptoms and anxiety was greater in the women who proceeded to parenthood than in the group who had a termination. It was also found that over a period of years the level of psychological consequence was equal between the two groups. That is international peer-reviewed research that to some extent speaks to the issue raised by the Deputy. However, we believed and were keen that the evidence we were asked to present to the committee should focus on the health of the woman, with no distinction being drawn between physical and mental health. The focus of our presentation related to the process of unplanned pregnancy as we experience it in our surgeries and the immediate as opposed to longer-term consequences of that.

Dr. Karena Hanley

There are consequences for every action in life and there will always be a certain number of women who regret their decision and it will always be part of our role to support and help them. I am conscious that this debate and media discussion about abortion must be very difficult for women who have difficulty conceiving and my heart goes out to them. An important point the Deputy raised prompts me to highlight that the role of a general practitioner must always be to provide non-directional counselling. In the context of the Deputy's point, it is very important that a general practitioner is not in any way directional in the advice he or she gives to a woman but must always support the woman's own decision.

The story the witness told about Sandra is only one of many. I am seeking balance. Many women regret having had an abortion. I do not know if the witnesses are familiar with the work of Dr. David Fergusson, who published a paper in the British Journal of Psychiatry. His paper tells the stories of many women who had abortions. Dr. O'Shea mentioned the website positiveoptions.ie. Women Hurt is a project initiated by women who regret having had abortions and wish to share their stories of hope and healing with women who find themselves in similar situations. The witnesses are discussing options. I would like people watching or listening to the committee proceedings to visit the Women Hurt website and learn of the experiences of those women. In the interest of balance, some of the doctors and consultants appearing before the committee should tell stories of women who had abortions and regretted it. I am sure the witnesses have met such women.

Dr. Brendan O'Shea

The Deputy is touching on our personal experience as practitioners and we have reservations about that. However, it is an important issue. All general practitioners are familiar with patients who have had painful experiences in their past because people come to us regarding a variety of events three, five, ten, 40 or 50 years after the event occurring. Child sexual abuse and non-accidental injury feature very prominently in that regard. My impression and belief is that the situation the Deputy described does not feature very highly. That is an impression, almost an opinion, not an objective fact and I am not trying to pretend it is.

The reason I keep emphasising this is that the witnesses mentioned one person's story. Women are having abortions and they have a voice and, in the interest of balance, I would like that voice to be expressed, especially if the stories come from those in positions of respect such as the witnesses.

The Deputy's point is well made and has been responded to.

I thank the witnesses for coming before the committee. It is very important that we hear from clinicians who are at the coal face and dealing with this issue. This may have already been answered but in terms of the eighth amendment raising difficult ethical issues for practitioners and general practitioner holding conflicting opinions or beliefs on the availability of abortion, do the witnesses think a lot of training would be needed for general practitioners? The witnesses may have answered that question but perhaps they could look at the bigger picture of increased numbers and GP training and so on.

Dr. Rhona Mahony, master of the National Maternity Hospital, Holles Street, and Professor Fergal Malone, master of the Rotunda Hospital, gave evidence to the committee yesterday. Dr. Mahony discussed the importance of sex education. Dr. O'Shea mentioned the importance of contraception and it being a key area and the myth about the pill. Are there other high-priority areas that are raised in general practices across the country, even on an anecdotal level, that the witnesses feel need to be targeted in schools?

Dr. Karena Hanley

In terms of any legislative change that may occur, approximately 10% of general practitioners conscientiously object to any form of abortion. That is a useful figure because it shows that there is a cohort of between 50% and 80% who would be available to deal with whatever legislation is enacted.

As we said before, we are in a very good position to adapt our training and to make sure the knowledge and skills are there.

Dr. Brendan O'Shea

If I understand it correctly, the question was whether there are other things we could do to make our society more contraceptive-smart and contraceptive-effective.

Anecdotally, in respect of sex education, the myths about the pill were mentioned. From Dr. O'Shea's experience or from talking to his peers, are there other issues in this area?

Dr. Brendan O'Shea

It is looking towards a real solution. It is a really important question. The genesis of the issues we are discussing is complex. Because it is a complex problem, the solution is going to be complex. No one size is going to fit everybody and there is no single solution. We actually have been effective in certain parts of public health messaging and we need to do more of it. The work that is being done by the Crisis Pregnancy Agency, for example, has been extremely helpful to us in practice but there needs to be more of it and it must be expressed through different modalities. There is a piece in education that needs to be built up and developed.

We deal with parents of adolescents frequently. Some girls and boys are well able to articulate these issues within their households, we understand, but the impression is that a lot of them - perhaps the majority of them - are not. Our educators could certainly be enfranchised, directed and trained to do more in this area of care so that we would be able to approach a situation where these topics, which are still difficult for many of us to discuss, could become easier. A key set of values and expectations could be built around service provision. A truly multidisciplinary approach could be taken. The practice nurse could be every bit as important and useful as the general practitioner, the community pharmacist and the public health nurse in this area of care. At the moment, bits of it are still hived off and broken up in a way that is not helpful for the public. If we did these things, we might be approaching having a society that is contraceptive-smart.

Dr. Karena Hanley

There are a number of initiatives driven particularly by our public health consultants, who in certain areas have set up fora with the local youth council, local women's organisations and local GPs as well as the obstetrics and gynaecology units in hospitals to try to further the best possible practice in reproductive health.

Dr. Brendan O'Shea

Within Irish society there is almost certainly a high level of high-risk behaviour in the community at the moment. We are not really behaving in a rational, reasonable way. From a public health perspective, there are analogies with where we were with driving ten years ago, when there were in the order of 600 fatalities with a smaller number of cars on the road. By dint of rigorous work through the Road Safety Authority, good legislation and education that number has been halved and is dropping. However, we cannot say the same of how the members' electorate, our patients and society at large is behaving sexually. People are taking casual risks on a regular basis. We need to make it easier and more direct for them to be able to engage in more effective behaviour and avoid these risks. Cost is still a significant barrier. It makes good sense at a societal level to eliminate that, by whatever mechanism the members as legislators decide upon.

Dr. Karena Hanley

One small area which would obviously help is that there have been cutbacks in student health services in all the third level institutions around the country. One simple way of improving access would be if those funding levels could be reinstated.

I call Deputy Bernard J. Durkan. Nobody else has indicated to speak so Deputy Durkan is the last.

Do not tell me I am the last. I thank our witnesses for coming before us this evening. As legislation stands at present, do they feel restricted in how they can deal with patients presenting with a crisis pregnancy?

Dr. Brendan O'Shea

Yes.

"Yes" is the answer to that question. For instance, would a pre-existing medical condition such as a tendency to high blood pressure constitute a crisis pregnancy? How does the present legislation affect the witnesses in their judgment in that regard, given that there have been a number of serious casualties - deaths - in such circumstances? How do they feel practices should deal with that kind of situation now?

Dr. Karena Hanley

Having been in medical practice in this country for 27 years, I have witnessed really tragic situations where a woman has lost her life through failure to terminate a pregnancy in time. I am so pleased to see the evolution of the Protection of Life During Pregnancy Act, which has clarified this area. We would leave the actual medical decisions to our obstetrics colleagues. It is heartening to have witnessed women actually being safer because of the development in legislation and the debate over the past 20 years.

In respect of young girls and teenagers presenting after an alleged rape, two questions arise. The first is about the availability of the appropriate treatment and the legality of it. The second concerns the situation in which sometimes the attack is not reported for various reasons. Can the witnesses tell us something about the factors that might restrict reporting in that area?

Dr. Brendan O'Shea

These are important instances and they do occur. They are complex consultations because there are several different elements that need to be considered, reflected on and reconciled along a set of priorities. The priorities should relate to establishing what has happened in a reliable way and, particularly, establishing the insight and concerns of the patient, establishing what her priorities are, considering the relevant legislation and taking the appropriate steps in terms of engaging with whatever additional agencies are required. These are uncommon situations but they are real and they are really important. It is complex consulting. That outlines the approach that a general practitioner would bring into the consultation.

Does Dr. O'Shea think the victim in a rape situation has a choice? Can she exercise that choice legally?

Dr. Brendan O'Shea

All things being equal - which they usually are not - the victim arguably does have a choice. Whether she is able to exercise that choice and whether her choice can be followed through on will vary from case to case and depending on what she decides.

Reference has already been made to the level of sex education in schools, etc. Does Dr. O'Shea think that sex education in schools has progressed sufficiently to be able to inform young women adequately in the event of something like that happening?

Dr. Brendan O'Shea

A lot has been done but there is a lot more to do, I think.

Dr. Karena Hanley

I do not really feel qualified to answer that question. It is outside of our domain and would be more a policy matter for the Department of Education and Skills.

Dr. Brendan O'Shea

In terms of our consulting, we consult with everybody and certainly with adolescents. At times, it appears that adolescents have quite a deep knowledge and are well able to find things out. However, a lot of the time they are not and a lot of the time there is huge misinformation going around in that adolescent head. It is a challenging area. While some progress has been made, we feel it would be a relatively small investment and an excellent one on the part of society to do more.

Dr. Karena Hanley

In our consultation with adolescents - this is not to do with formal education in schools - we often direct them to really good websites. There are a number of very good HSE-provided websites which provide excellent information on reproductive health, SpunOut.ie being one of them.

In last evening's presentation, Dr. Abigail Aiken produced quite an interesting chart.

It showed people post-abortion who were satisfied, more than satisfied, less than satisfied and felt ill at ease. I believe that last category was 42% or 43%. This question was asked yesterday - is adequate backup, counselling and medical assistance available afterwards in the event of a woman post abortion finding herself in that situation? Mentally and-----

I will correct a point. To be accurate, nothing in Dr. Aiken's study stated that 43% of women were ill at ease afterwards.

I was intending to clarify that in a moment.

It is important that information like that not go out.

No. With all due respect,-----

Will we get the chance to-----

-----I will continue to ask the questions as I see them.

We will have one speaker, but we will ask Deputy Durkan to finish up and I will clarify after that.

There was a considerable cohort of women in that category for one reason or another.

Does the Deputy have that information there?

Please. The question is-----

Some 98% felt that they had made the right choice.

Sorry, Deputy. I will clarify it.

Are adequate backup and support services available, for example, medical services, psychiatric support services or whatever the case may be?

Dr. Brendan O'Shea

There are two parts to the answer. There is a part that relates to the HSE, that is, hospital-based services and allied counselling agencies that are put in place or maintained by the HSE. We do not feel qualified to give an opinion on that. There is a general practice part, which relates to the care and support that can be provided by general practitioners, GPs, and practice nurses. In key respects, the service is available and the practices are receptive. For the third time, I will say that all practices are stretched well beyond what is safe and acceptable in the generality of what they are trying to provide. That is a concern.

Another concern is that, because of the criminalisation of the process and even though the services may be available, there are barriers to vulnerable patients who have undergone a difficult, challenging experience easily accessing those services. The services may be there, but the isolating and traumatising effect of the experience can interfere with the ability of the person to engage with the service.

How is the best-----

I am sorry, but the Deputy is over time. Is that okay?

I am the only person who was interrupted in the course of the few words that I had to say and I am the last person to speak, and I object strongly----

It is just that there are eight minutes remaining, but if the Deputy wants to finish-----

Now, hold on a second. I am not coming from one opinion or another.

I happen to be the only person who was interrupted in the course of questioning.

That is because-----

I base my questions on my own knowledge of the situation. Other speakers went well over time.

I will leave it at that.

Actually, very few members went over time today.

I have been recording each of them. I have no wish to interrupt the Deputy, so if he wishes to finish on a particular point, please go ahead.

I was attempting to finish the point.

Please, do.

It concerns the barriers to psychological or medical advice. How can we best resolve that particular problem?

Dr. Karena Hanley

There are free post-abortion counselling services in Ireland. They can be accessed through a website, www.abortionaftercare.ie, which is funded by the HSE. This gives the woman a safe space in which to explore and articulate her feelings, whatever they may be, towards the experience that she has had. It is available to the woman even several years after the event, if necessary. Perhaps it is something that needs greater advertisement throughout the country, but the service is available.

Dr. Karena Hanley

Absolutely.

I thank the Chairman.

To be clear, I was attempting to clarify afterwards so that Deputy Durkan could continue with what he was saying. Dr. Abigail Aiken stated:

When Irish women choose this online telemedicine model, what are their experiences? Exhibit 6 [we normally have screens, but we cannot show this exhibit today because we do not have screens in this particular committee room] shows the feelings reported by 1,000 women who went through the early medication abortion with Women on Web between 2010 and 2012... 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.

That is what Senator-----

That is not the answer to the question at all. The chart specifically showed a series of five situations. Will the Chairman read those out for the purposes of clarity and fairness?

That was the exhibit.

I certainly will, but I was addressing what Senator Ruane was seeking to do in the middle of the Deputy's contribution as distinct from that.

If one adds the various figures up, one will find that what I said was accurate.

Exhibit 6 reads: relieved - 70%; and satisfied - 35.8%. The other figures were 26.8%, 22.1%, 17.4%, 11.6%, etc. Dr. Aiken made the point that these did not add up because of the way in which the study was done.

We know that, but they are also in the chart, as are the figures on the other side, which are there for everyone to see.

I have sat and listened to the whole debate, but I want to ask a question in the interests of balance. Do patients in crisis pregnancy situations who choose to have their babies tell their GPs, who are normally their first point of contact afterwards, that they were happy with their decisions?

Dr. Karena Hanley

Of course. In fact, that is the majority of the outcomes of crisis pregnancies. It is wonderful to see that. Positive parenthood is something that we all support.

I thank the witnesses for taking the time to attend this useful session and answer members' questions.

If I might have members' attention for a minute or two before we conclude, we have arranged to hold a meeting with our legal adviser next Tuesday at approximately 5 p.m., with the venue to be confirmed. Thereafter, we will arrange a public session meeting, which I hope will be on Wednesday evening as discussed earlier during private session.

The first week of November is a non-sitting week. Is the committee proposing to sit that week? Given our workload, it might be advisable that we not sit that week and instead jam in a few extra meetings. We could all probably do with a break by that stage.

Given that we have such a short time available to us, I propose that the meetings that would ordinarily be scheduled for that week be rescheduled to either side of it, if possible. We could put an extra hour and a half in the schedule so that people will have the opportunity that week to digest everything that has been covered so far. Would that be agreeable?

Could we try not to let it go into other days and across other meetings?

In so far as possible, we will hold the meeting on Wednesday afternoon.

I wish to raise a final point on the public session meeting. I am not trying to delay us.

Certainly.

We need clarity as to when it will be. The Tuesday session-----

I believe it will be on Wednesday.

Will it be, though? We need to book our own free time. If we are debating something as important as this issue, ample notice needs to be given to people. We cannot just arrive on Tuesday and get this agreed.

We will email tomorrow to confirm the venue. It is merely a question of checking the availability of committee rooms. I imagine that we will take the witnesses whom we have scheduled first and, as Deputy O'Brien suggested, meet thereafter. Perhaps it will be in the same committee room, but if we have to move around-----

It will be after the other Wednesday session.

On Wednesday afterwards is what we are thinking, if that is agreeable with the committee.

Yes. It is just so that everyone can know and people will not say next week that they are sorry because they did not know. Everyone knows.

I would prefer it if we could give people as much notice as possible.

If there is no other business, we will adjourn until next Tuesday.

The joint committee adjourned at 4.40 p.m. until 1.30 p.m. on Wednesday, 18 October 2017.