Health Care Issues - Crisis Pregnancy Management: Ms Janice Donlon, HSE

I welcome the witnesses to this afternoon's meeting. I have already asked them if they are aware of the defamation issues. If there is any issue I will highlight that.

I invite Ms Donlon to make her presentation.

Ms Janice Donlon

I thank the Chairman for inviting us here today. My name is Janice Donlon and I am the project manager for funded services with the Health Service Executive, HSE, sexual health and crisis pregnancy programme. I am joined today by Helen Deely who is the head of the programme. We have been asked to address the committee on the supports provided by the HSE sexual health and crisis pregnancy programme and on the use of the abortion pill.

The information will be presented in two sections: first, I will outline supports provided by the programme to those experiencing a crisis pregnancy. I will then talk about behavioural trends and research relating to crisis pregnancy, including use of the abortion pill.

The HSE sexual health and crisis pregnancy programme is a national programme situated within the health and well-being division of the HSE. The programme is mandated by a statutory instrument to reduce the number of crisis pregnancies and to provide support to those who have a crisis pregnancy. Legislation defines crisis pregnancy as "a pregnancy which is neither planned nor desired by the woman concerned and which represents a personal crisis for her". The programme understands this definition to also include the experiences of those women for whom a planned or desired pregnancy develops into a crisis over time due to a change in circumstances.

A pregnancy may be considered a crisis for several reasons. Crisis pregnancy can be related to a perceived inability to cope with a child at that time; being too young or too old; not being in a financial position to support a child; and the potential impact that becoming a parent at that point might have on their education, training or employment. Research finds that approximately one third of women who have been pregnant and one fifth of men who have experienced a pregnancy in their lifetime have experienced a crisis pregnancy.

The programme funds 15 individual crisis pregnancy counselling services which operate out of 40 plus locations nationwide to provide free crisis pregnancy counselling. Details of these crisis pregnancy counselling services can be found on www.positiveoptions.ie. Crisis pregnancy counselling and information on all three options: parenting, adoption and abortion are provided under the legal framework of Regulation of Information (Services outside the State for Termination of Pregnancies) Act 1995, also known as the abortion information Act. The Act sets out how information about legal abortion services outside Ireland may be given to individuals or groups in Ireland.

Crisis pregnancy counselling services are funded by the HSE under detailed governance arrangements and underpinned by a quality framework, including access to supervision and training supports and guidelines and protocols to support services and their staff working in this complex area.

Counselling for a woman involves creating space to allow her to discuss and reflect on her crisis pregnancy and to support her through the decision-making process. While many women experiencing a crisis pregnancy resolve the crisis for themselves, or have support from family and friends, research finds that they see a clear role for a counsellor. The importance of a supportive listener and non-judgmental support allows them to consider how the pregnancy impacts on their lives. It is the counsellor's role to provide space and time to facilitate women to work through difficult conflicts in a non-judgmental and non-directive manner.

During a counselling session the client may request information on the options available to her. Any woman considering parenting a child will be made aware of the various organisations and community support groups that offer information and support in relation to parenting, either alone or as a couple. Many of these organisations are also funded through the programme. Such organisations and groups have detailed user-friendly booklets touching on many issues of parenting, including information on rights and entitlements and accessing support services.

In respect of adoption crisis pregnancy counsellors are able to provide a client with some of the basic principles surrounding the process of adoption and the rights of birth parents and adoptive parents. However, if a woman chooses adoption as an option she will be appropriately counselled and advised at all stages of the adoption process by an adoption social worker, either with the Tusla adoption service or an accredited body.

If, after appropriate counselling on all options, a woman makes the decision to terminate her pregnancy she should be given as much information as is necessary. Information about abortion services in other countries may be made available under certain conditions. The law on the subject was passed in 1995 and is usually known as the abortion information Act. The Act sets out how information about legal abortion services outside Ireland may be given to individuals. Information on how to access abortion services, including names and addresses of clinics can be provided as can information on the types of procedure that may be available to her. Crisis pregnancy counsellors are not medically trained and any specific medical questions are referred to the woman's general practitioner.

All information should be provided in a manner that is accurate, unbiased, impartial and in accordance with the law. This is necessary to allow the woman to make an informed decision as to the most appropriate course of action for her. Information may be given in different formats, including written material which the client can take home with her.

The numbers of women attending crisis pregnancy counselling services has fallen significantly in recent years. In 2010 4,662 individual clients attended for crisis pregnancy counselling, by 2016 that number had fallen to 2,570. The majority of women attending crisis pregnancy counselling services are between the ages of 25 and 34.

The programme has identified one other main provider of the abortion pill and has sought similar information from this provider for a more accurate assessment of the trend.

If a woman takes an abortion pill and has prolonged heavy bleeding, bad pain, fainting or other complications we strongly encourage that she attends an emergency department or GP straight away. If a woman is concerned about her health following taking an abortion pill, we would encourage her to attend a free post-abortion medical check-up funded by the HSE. A list of these services is available on abortionaftercare.ie.

I thank the committee members for their attention. Helen and I are happy to take any questions that the committee may have.

It is recognised by us and the services that in the 20 years since the commencement of the Regulation of Information (Services Outside the State For Termination of Pregnancies) Act 1995 there have been many developments in technology, including access to the Internet. Many women are now bypassing crisis pregnancy counselling services and accessing information on abortion services directly from the Internet. While the numbers attending services are decreasing, counselling services report that those attending services are presenting with more complex and multiple issues. The challenge for the programme and the counselling services is to ensure that women in most need of crisis pregnancy services and supports feel that the services are relevant to them and will meet their needs.
Many of the counselling services funded by the programme also support women and their partners through the diagnosis of a fatal foetal abnormality or life limiting condition. Additional training and support has been provided to these services to ensure they are able to respond to the needs of this client group. Counselling services have forged links with maternity units and have the expertise and the capacity to support women and their partners through this difficult time.
I shall now turn to the issue of crisis pregnancy agencies, which are not funded by the State. Some organisations that advertise as crisis pregnancy counselling services have a hidden agenda. The service they provide is designed to influence the choice a woman makes and to pressure a woman into doing something she may not want to do. Once these agencies have been contacted by a client they can seek to delay the counselling process and, in certain cases, show clients inappropriate images or use other tactics in an effort to influence their decision. These organisations are not State funded and women are advised to find out as much information as possible about a pregnancy service before they make an appointment. All HSE sexual health and crisis pregnancy programme funded services are advertised on positiveoptions.ie and will provide non-directive, non-judgmental counselling.
Post-abortion services that are available include post-abortion counselling provided by the same funded services which provide crisis pregnancy counselling. Details of these post-abortion counselling providers are available on abortionaftercare.ie.
Information on the availability of free post-abortion counselling in Ireland is also provided by abortion clinics in the UK and the Netherlands. The programme links with abortion providers to ensure the information is made available to women who have travelled from Ireland. Post-abortion psychological support allows a woman a safe space in which to explore and articulate her feelings, whatever they may be, towards the decision made and perhaps the experience of the abortion itself. A client may require a number of counselling sessions post abortion and the counsellor is available to support the woman depending on her individual needs. A woman may attend for post-abortion counselling shortly after her abortion or she may attend at a later stage if issues emerge related to other life events. The number of women who access post-abortion counselling has remained steady over the last number of years and in 2016 a total of 1,377 clients were seen for post-abortion counselling.
A post-abortion medical check-up is also available for women to ensure they have fully recovered from their procedure. A post-abortion check-up normally involves a blood pressure check and an examination of the woman's abdomen. The doctor will confirm that the pregnancy has ended, check that bleeding pattern is normal and there is no infection and will assist the client with their contraceptive needs.
A number of the services funded to provide crisis pregnancy and post-abortion counselling services also provide free post-abortion medical check-ups. The details of these services are available on abortionaftercare.ie. Attendance at the medical checkup also allows an opportunity for the doctor to refer the women to post-abortion counselling if such a referral appears beneficial. The numbers attending these services is low; in 2016, a total of 442 women attended medical check-ups funded by the programme. Women may attend their GP on their return if required or, depending on the type of procedure they have undergone, may not require a post-abortion medical check-up, for example with early medical abortion.
I shall now address some behavioural trends and the research relating to crisis pregnancy, including use of the abortion pill. As a core function of its work, the programme monitors behavioural trends relating to its mandates, using a range of tools and indicators including general population surveys and statistics. Research informs us that crisis pregnancies happen to women and their partners from all different ages, socio-economic backgrounds and with different relationship statuses. The majority are married, engaged or in steady relationships when the crisis pregnancy occurs. The most common reasons the pregnancy is seen as a crisis is because it was not planned or the woman and her partner consider themselves too young. The average age at which a crisis pregnancy occurs is stable at 24 years for women and 25 years for men.
When we consider the outcomes of crisis pregnancy we can see that parenting is by far the most common outcome for those who experience a crisis pregnancy. A survey of the general population found that when asked about their most recent crisis pregnancy 73% of women reported that they chose to parent. In the same general population survey, 2% of those asked about their most recent crisis pregnancy reported that they chose adoption. Traditionally in Ireland adoption was a common response for women experiencing a crisis pregnancy; however, the number of women placing their babies for adoption has decreased significantly in recent decades. A figure of 24% of women in the same general population survey who reported experience of a crisis pregnancy reported that they chose to have an abortion following their most recent crisis pregnancy.
With regard to abortions in other jurisdictions it is well documented that many women travel from Ireland to other countries to access legal abortion services. The programme analyses data collated by the Department of Health in the UK and the Ministry of Health in the Netherlands on the number of women travelling to those countries from Ireland for an abortion on an annual basis. In the majority of cases, women travelling from Ireland for an abortion travel to England. In 2016, a total of 3,265 women gave Irish addresses at UK abortion services, representing a rate of 3.2 per 1,000 women. There has been a gradual decline in the number of women availing of abortion services in the UK since 2001. In that year there were 6,673 abortions to women from Ireland in UK abortion clinics, representing a rate of 7.5 per 1,000 women. The Ministry of Health in the Netherlands has collated data on women providing Irish addresses in Dutch abortion clinics since 2010. Prior to 2010, the programme linked directly with the main abortion service providers in the Netherlands to establish the number of women providing Irish addresses there. In 2015, 34 women were recorded to have provided Irish addresses in abortion clinics in the Netherlands. These figures have significantly declined since their peak in 2006 when the number was 461. The Netherlands has emerged as the only other jurisdiction to which women from Ireland have been travelling for abortion procedures in any significant numbers.
I shall now turn to the numbers of abortions in Ireland under the Protection of Life During Pregnancy Act 2013. The Act defines the circumstances within which abortion in Ireland can be legally performed. The total number of abortions carried out in accordance with this Act in 2016 was 25. There were 26 in each of the years 2014 and 2015, with 2014 being the first year in which data was reported.
On the issue of abortion pills, they are designed to induce an abortion for a woman who is less than nine weeks pregnant. Abortion pills are used by abortion providers in medically supervised clinics in countries where abortion is legal. These are referred to as medical abortions. The programme is aware that some women are accessing abortion pills in Ireland from international online providers. In order to try to understand the incidence of this, the programme set up a reporting relationship with the Health Products Regulatory Authority in relation to the number of abortion pills seized by customs officers annually. The programme has provided training and support to all funded services on this emerging issue. All services have developed protocols in this area and training manuals and online resources have been updated with relevant information.
The reasons women may be accessing abortion pills online are cost and access. For women who have made the decision to terminate a pregnancy, the cost associated with travelling from Ireland to another country for a medically supervised termination is high. Research finds that higher earning women are more likely to travel to other countries for abortions over their lower earning counterparts. Until recently it was difficult to make an assessment of the level to which this practice is occurring as limited information was available. Recently published research suggests that more women are contacting online providers of abortion pills annually and becoming more aware about the availability of these drugs online. As the committee has been informed by a previous witness Dr. Abigail Aiken, her study found that over the period January 2010 to December 2016 the number of women from Ireland who contacted an online provider of abortion pills tripled. In 2010 there were 548 online consultations completed by women from the island of Ireland. In 2016, the number had increased to 1,748.
Another research article, published by the same authors in 2017, reports on the experiences of women following taking the abortion pill in Ireland. The study reports on 1,000 women who underwent self-sourced medical abortion from the online service. The study reports that while the vast majority of women did not need to contact medical services following taking the abortion pill at home, approximately one in ten - 9.3% - reported to the online provider that they were experiencing a symptom for which they were advised to seek medical advice and the vast majority of these women sought medical advice as advised.

I thank Ms Donlon. I call on Senator Gavan to use the remainder of Deputy O'Brien's time. He has about six minutes.

I thank the Chairman. I thank Ms Donlon for coming to the committee today and for her presentation.

My first question relates to the HSE crisis pregnancy website. It states that it has three mandates, one of which is "A reduction in the number of women with crisis pregnancies who opt for abortion by offering services and support which make other options more attractive". I am a little bit confused because page 2 of Ms Donlon's presentation says that the HSE services are to be provided in a non-directive, non-judgmental and client-centred manner. If a woman feels that her needs are best met by an abortion what are these other options that the HSE mentions on its website? Is this a case of directive counselling to the woman to continue with the pregnancy or are there other options we are unaware of? Perhaps Ms Donlon will elaborate on these because it appears to me to be contradictory with regard to the HSE website and what Ms Donlon has said here. I can see only two options available for women in those circumstances.

Ms Janice Donlon

I thank Senator Gavan for the questions. The mandates certainly set out the exploring of other options. The way that we interpret the mandates, as set out by the crisis pregnancy legislation, is by providing non-directive and non-judgmental counselling. That is set out in the law also in respect of providing that level of support for women. We feel that counselling provides the space and the time for women to explore all of their options in a safe, secure and non-judgmental manner. We absolutely are not directive in any of our instructions around our mandates and we absolutely support the provision on non-directive, non-judgmental counselling. Counselling allows a woman the space and time to discuss all of her options, and to explore how each of the options may impact on her life. If the woman wants to explore the option of parenting she is given enough support and information to consider that and how it would impact on her individual set of circumstances.

The programme has provided funding over the years to other organisations to provide supports to those who choose to parent. A number of the organisations we fund provide support and training to one parent families and additional supports in that area. Equally, we provide funding to a crisis pregnancy counselling service that has expertise in adoption. If a woman chooses to explore that option she is given enough information to be able to make that decision. Our mandates allow us to ensure that women are directed towards counselling that is non-judgmental and non-directive. This is what we fund in counselling services.

I thank Ms Donlon for that answer. I accept what she has said but I do see a contradiction in what the witness has said and what is on the website. I wish to flag this. The website certainly suggests directive counselling to some degree.

I am conscious of time and I shall move on. There is lots of really good information in the presentation and I thank Ms Donlon for that.

Considering the number of women on record who have travelled to Britain for termination of pregnancy and who have obtained abortion pills online, does Ms Donlon feel that the HSE is leaving thousands of women vulnerable each year? In fairness, there is a huge gap between the HSE figures of people who get post-abortion counselling and the annual figures for those who actually travel for an abortion. There are thousands in the difference there.

Ms Janice Donlon

I believe that international evidence would also show that the number of women who take up post-abortion counselling is low internationally. That trend is similar in Ireland. Women do not often identify that they need counselling after an abortion. It is realistic to understand that many women do not require counselling. Some women do and our services are available to those women. The counselling services that we fund report that women often attend for post-abortion counselling many years after they have experienced an abortion. It is not necessarily straight after their experience that they seek counselling. It may be down the line. International evidence would show that women do not seek or do not feel that they require counselling post-abortion, and this is reflected in the numbers here also.

Has the crisis pregnancy programme received any complaints regarding the advice given to women, and if so will Ms Donlon give the committee some details on what sorts of complaints have been made?

Ms Janice Donlon

Certainly since the funded services have come under the HSE, and in my time, we have not received complaints. All of the 15 services have robust complaints procedures and have mechanisms for service user feedback. All of the complaints would be sent in to the consumer affairs division of the HSE as is outlined in their service arrangement for the protocol around where complaints are directed. The complaints would also be directed to us in the programme. We have not received complaints about the services we fund. There are complaints in respect of other agencies, such as the rogue agencies or disingenuous agencies that are not funded by the State. Those complaints would come to the services we fund and this is where we would see them.

On that last point, I know it is implied but I wish to make it clear, those rogue agencies referred to by Ms Donlon are the agencies that try to persuade women not to have a termination.

Ms Janice Donlon

Absolutely. We know that they target women who are seeking information on abortion. They target them by delaying them in their decision making process. This is information we get from the funded services that see these clients. The clients have been through quite a traumatic time with those rogue agencies. Our funded services then see them and try to support them through their decision-making process.

I thank Ms Donlon very much.

I shall ask Ms Donlon the same question I asked of Dr. Henchion. Will Ms Donlon tell the committee what her organisation has done specifically to promote adoption as an alternative to abortion? How many conferences has it run? What percentage of her programme's tax funding goes on this area compared to how much it spends in researching and discussing abortion and the possibility of repealing the eighth amendment?

Ms Janice Donlon

Our primary focus in the programme is to fund crisis pregnancy counselling services to provide non-directive and non-judgmental counselling. In that guise we do not direct funding or our services towards any one option because those options are there for the client's individual decision in respect of her crisis pregnancy and for her own particular set of circumstances. Absolutely there is information available for all clients should they seek information on adoption. As I said earlier, one of the services we fund has experience in adoption. We would certainly support women who make the decision to go down the road of adoption. All of the options are available to women. A woman comes to a counselling service in crisis. She comes in turmoil at what has happened to her. She cannot believe that she is pregnant and the counsellor's role is to support the woman through that crisis, to support her through the decisions she will make and support her in teasing out how those decisions will impact on her life. It is not directive counselling. It is not about the counsellor's opinion of what option may be best for the client. The counsellor's role is to support the client through her decision making process. Often the counselling services report that women consider many options through the counselling sessions.

Women attend more than one counselling session and are invited to attend more than one session until they are happy they have made the decision that is right for them at that point in their lives. None of our funding and none of our mandates in terms of what we tell services to do is about directing them towards a certain option. We would be going against the non-directive, non-judgmental counselling service provision if we did that.

On page 2 of the presentation, it states that the programme funds 15 individual crisis pregnancy consultation services which operate at more than 40 locations nationally to provide free crisis pregnancy counselling. It is a very large catchment area. It also states on page 2 that, during a counselling session, a client may request information on the options available to her. What information is provided to clients surrounding the process of adoption?

Ms Janice Donlon

As I have said, if a client seeks information on adoption from a counsellor during a counselling session and wants to explore the option of adoption, she is absolutely given as much information as possible to feel supported in that decision. While it may require the counsellor to refer her to a more specialist service such as a Tusla adoption service or an accredited body where she seeks further information on that option, the client is given as much information as she needs for her to feel she can make that decision. It is not that there is no information there. The counsellor has all of the information the client needs in her decision-making process.

The programme did a general survey on the outcome of crisis pregnancies which found that parenting was 73%, abortion was 24% and adoption was 2%. Why has adoption decreased so significantly over the past decades?

There are no forced adoptions.

I am not asking the Senator the question.

It is just a point of order that answers it.

Please, do not interrupt Deputy Fitzpatrick.

There was no need for that. Senator Ruane had an opportunity to ask her questions.

Ms Janice Donlon

We do not have research as to why women are not choosing the option of adoption anymore. As a society, the option of adoption is not considered as much as it has been in the past. From a crisis pregnancy counselling point of view, certainly, if the woman chooses that option, she is able to explore it in terms of being provided with enough information to make that decision. We do not have statistics on the reasons that option is not chosen as much as it was in the past.

Are organisations providing enough information on adoption? One can find out about abortion clinics on the Internet and there are even abortion clinics which offer bonuses to their employees to get people to avail of abortions. Is enough being done with the HSE on the option of adoption in a crisis pregnancy?

Ms Janice Donlon

It is down to the individual client. If she seeks information on adoption, the counsellor has the resources, the information and the referral to the specialist services should the client wish to explore the option. Absolutely, the information is there if the client requests it.

Ms Janice Donlon

It is there from the HSE, from Tusla, which is the authority in relation to adoption, and the Adoption Authority. The information is available should the client request it.

Reading the presentation, it appeared to me that if a person seeks information from the programme and asks directly for a child to be adopted, she would be referred by the HSE to Tusla.

Ms Janice Donlon

Absolutely, that is the process.

What I want to know about is where she comes in and does not know what she wants. Is enough information being given then on the process of adopting a child?

Ms Janice Donlon

If that is what the client is requesting. If the client comes in and is exploring all of her options, she is given as much information on each of the options as she needs for her to make her decision based on her individual circumstances. Absolutely, the funded crisis pregnancy counselling services have that information available should the client require it.

I thank the witnesses for attending. I presume Ms Donlon would describe the presentation today as "neutral". It is the service the HSE runs and it is not an advocate for any side.

Ms Janice Donlon

No.

I just want to establish that because there are all sorts of people coming in front of us and being put into categories they would be astonished to find themselves in. Ms Donlon said in her presentation many women experiencing a crisis pregnancy resolve that crisis for themselves. They must resolve that crisis for themselves because we are not in a situation where there is a legal abortion regime except in situations where the life of a woman is at risk. That is fair to say. What do the HSE's counterparts in countries where there is a legal arrangement do? Would the HSE's role be very different should the eighth amendment be amended? Has the programme given that any consideration?

Ms Janice Donlon

Crisis pregnancy is unique in terms of trying to compare it with international counterparts and evidence. The provision of crisis pregnancy counselling is unique in the State funding it receives. That is not seen in other jurisdictions where abortion is legal. What the HSE has is a unique set-up in terms of funding counselling services and it is not replicated, as far as we can see, in jurisdictions where abortion is legal.

Ms Donlon said the numbers presenting to the programme were falling. Does that suggest that many women in the past would have come for information rather than counselling? Once they can get if for themselves, they do not require counselling.

Ms Janice Donlon

Yes. The Crisis Pregnancy Agency was established in 2001 and the HSE assumed responsibility for it in 2010. In the early stages, women certainly were accessing crisis pregnancy counsellors in order to gain information on abortion clinics in the UK as that information was not widely available at the time. With the advance of the Internet, people who are only seeking information on where the clinics are located and so on are certainly not attending the services. The services inform us that those types of client are not attending the services any more. Those attending do so with more complex needs around other areas of their lives and seek a counselling service to find the space and time to consider their decisions.

In relation to the abortion pill, Ms Donlon is saying approximately one in ten women, or 9.3%, reported to an online provider that she was experiencing a symptom and was advised to seek medical advice. One of the things that has cropped up as having the potential to prevent women seeking medical advice was referred to by our last contributor. It is the potential to be reported due to illegality with consequences for that. What approach does the HSE take to advise and reassure women that they should not fear seeking medical advice?

Ms Janice Donlon

Our priority and that of the funded services and their ethic of care is to support women and not dissuade them from attending either medical or counselling services where they have taken the abortion pill. Our website, www.abortionaftercare.ie, has information that encourages women with complications following the taking of the abortion pill to seek medical advice and not to be fearful in doing so. It is an incredibly difficult area for the woman and the counsellor to support a woman through this.

It is a difficult area for the woman and it is a difficult area for the counsellor in terms of supporting a woman through this, but our primary concern is that women are not dissuaded from seeking the medical attention they require should they have complications.

With regard to the seizure of abortion pills by customs officers, does Ms Donlon have any indication of the quantities involved? Were they intended for individual homes? If somebody is looking to take medication to terminate a pregnancy, there is a critically important timeline. It would be useful to get that information if Ms Donlon has it.

Ms Janice Donlon

The programme has a reporting relationship with the Health Products Regulatory Authority, HPRA, in terms of the number of cases of abortifacient tablets seized by customs. We have data from 2008 up to 2016. In 2016, for example, 536 abortifacients were seized; in 2014, that number was 1,017. It seems that the number of seizures by customs has reduced. Evidence may have come through Dr. Abigail Aiken's research on the abortion pill that women are finding alternative methods of importing the abortion pill. That may be through using Parcel Motel or those sort of providers and the numbers may reflect that in terms of customs seizures. We established that relationship with the HPRA in the absence of any other information that we had on the use of the abortion pill. We were trying to see trends in terms of seizures. Now that we have that reporting relationship and we have understanding through Dr. Aiken's research, we are better able to establish trends in the numbers of women who are accessing abortion pills online.

I am quite certain that it must add to the stress.

I call on Senator Mullen. He has six minutes.

I welcome our guests and thank them for an extremely informative presentation. I would like to say that, in my view, there was certainly nothing tendentious about their presentation, and would that more had been like them in recent weeks in coming before the committee and laying out the facts very clearly according to Ms Donlon's experience and remit. I would like to ask about that remit, however. I understand that Ms Donlon's brief here is to explain what she does in the light of the mandate she has, not to advocate for policy, legislative or constitutional change. Where are the terms "non-directive" and "non-judgmental" defined?

Ms Janice Donlon

They are defined in the abortion information Act in terms of the provision that all information should be provided in a non-judgmental, non-directive manner. I think also-----

Can we tease this out? Are the terms themselves defined in the legislation?

Ms Janice Donlon

In the abortion information Act?

Yes, or indeed anywhere else. The requirement is there, but is what the terms mean defined?

Ms Janice Donlon

I am not aware of the interpretation in that manner.

It seems to me that so much of what the programme does is determined by the witnesses' understanding of what non-judgmentalism and non-directiveness actually require. Let me put it this way: we operate within a constitutional framework where the unborn baby is another person to be protected by Irish law, the second human being involved in the equation. In other areas of our culture, we have very good, proactive and State-funded activity designed to discourage behaviours that might be harmful to individuals themselves or to a third party. I am thinking about anti-drink and anti-smoking campaigns, drink-driving, and, increasingly, anti-obesity. These campaigns are publicly funded. One would not so much describe them as directive and judgmental because they do not judge the people and nor do they require or coerce certain kinds of behaviour, but they do clearly encourage or indeed discourage certain behaviours.

I do not expect Ms Donlon to comment on the anomaly, because that would bring her into the realm of policy, but it seems anomalous that, on the one hand, we can encourage certain kinds of behaviours for the sake of protecting an individual, or a third party in the case of drinking and driving and so on, but that when it comes to the protection of the unborn and how that intersects with Ms Donlon's work, it seems to me that the positive options notion sums up her activity, which is to say that as long as the information is procured, supplied and accurately provided when requested, Ms Donlon's job is done. Is this because the programme sees itself as being curbed by legislation that there is not something more proactive done given our constitutional position, which one would understand ought to tend the State towards protecting the unborn? I am asking about things like recommending adoption or requiring that State-funded agencies propose or speak positively of adoption as an alternative.

I am also talking about things like informed consent. We had a hearing last week in which it was not effectively accepted but it was certainly not contradicted, that there is no evidence linking abortion with increased mental health outcomes, yet mental health is what is on the Statute Book in Britain and it is what has opened up a large number of abortions. Mental health was also cited by the IFPA here earlier. Does the HSE crisis pregnancy programme require, as a matter of informed consent, that counsellors draw a woman's attention to the possibility that if she had, for example, a previous mental health history she might be at risk of adverse mental health sequelae in the context of abortion? This is no more and no less than the precise truth.

Take the question of ultrasound. I am not asking Ms Donlon whether it ought to be required that a woman see an ultrasound, but ought it be required of counsellors that they offer that in a respectful way and in a way that always respects a woman's right to refuse, but also in a way that allows the provision and sharing of full information, all of which might act to encourage the life-giving choice at the end of the day? Does Ms Donlon see that as outside of her mandate? Would it require a change of law in her view for public policy to go down that road in the light of what the eighth amendment currently states as a matter of public policy?

Senator Mullen has spoken for five minutes now. He has to allow the witness to respond.

Ms Janice Donlon

If the question is whether we would in any way encourage any sort of directive in the provision of information and on how options are presented to the woman, taking away our position, if we look at good counselling practice, it would ensure that the woman is seen as an individual who is able to have self-determination around her options. She is seen in a non-judgmental and non-directive way in relation to the provision of information. That is how the counselling services operate, and it is good counselling practice to operate in that manner. The individual is coming to the counsellor in a crisis. She is confused, unsure as to what her options are, and unsure as to what option she may ultimately decide upon. She ultimately needs that time, space and reflection to consider all of her options.

Ms Donlon's reply seems to beg a question, however, because she uses the word "directive" as though directive is defined. I infer from what she is saying that she has a notion that what current counselling practice regards as directive would be that kind of behaviour that is, for example, suggestive of a better outcome. I put it to Ms Dolan, however, that is not necessarily the only case and one could interpret, in light of the Irish Constitution, that it is not directive to suggest, rather it is suggestive or that it proposes something.

I will allow Ms Donlon to clarify that point and I will then move on to the next questioner.

Ms Janice Donlon

Again, we support the provision of counselling that does not direct or persuade a woman towards any one option. It is the individual woman's right to decide on the options that she wants to explore, and to get as much information on those options as she needs to feel comfortable in making her decision.

I thank the Chair for her indulgence. Before I conclude, I wish to say that there are many other important issues, including the question of whether the IFPA engaged in rogue activity, which I would like to have raised-----

Perhaps other members will ask that.

I only wish it would happen. My time is up.

Hopefully it will.

I thank the witnesses for attending. If the HSE were to improve the quality and extent of its services, does Ms Donlon see any particular area where improvement is desirable now or at some time in the future? Expansion, availability throughout the country-----

Ms Janice Donlon

Expansion and availability do not appear to be a problem throughout the country. We are looking at introducing a telephone counselling service, probably from next year, which will ensure that the service is more accessible and available. Currently, it is a face-to-face counselling service. The law and the restriction of the law is complex for counsellors and for women. That is what they have to operate within. We offer counsellors as much support, training and guidance as possible so that they can operate within the law and support women through the process.

Are the services reasonably evenly spread throughout all areas of the country?

Ms Janice Donlon

Yes. We have no problem in terms of access to or availability of services.

I welcome our witnesses and thank them for attending. When listening to Ms Donlon's presentation, I reflected on the fact that it has been many years since I marched with my mother on the streets of Dublin for the right to information. I said to my mother at the time, "This is ridiculous. This is only information." Of course, now there is a raft of information available, not only from the HSE. Ms Donlon states that there has been a gradual decline in the numbers travelling and a gradual increase in the number of women who are accessing abortion pills online. Presumably, given that the one is going down and the other is going up, we can say that the number of women accessing abortion care is remaining relatively steady, as is the number availing of counselling, 442, which, as Ms Donlon said, is very low. There is an great deal of information out there, which can be accessed with a few clicks of a mouse. Women know that the services are available, that the aftercare and emotional support are there, should they require them. However, the figure for those availing of counselling remains consistently low. Would it be true to say that this would indicate that women are happy with their choice and have no need for follow-up counselling? Perhaps Ms Donlon could elaborate on that?

On the rogue agencies, I am thinking particularly about work done by the journalist Ellen Coyne on those agencies that will tell women that if they have had abortions, they are at greater risk of breast cancer and other nonsense of that nature which we know has no basis in medicine. Ms Donlon says those agencies target women in crisis pregnancy. Could she elaborate on how that is done? I echo what my colleague said - we do not often find ourselves agreeing with Fine Gael but we will say so when it happens. I welcome the moves by the Minister to regulate these agencies, particularly those which were highlighted in the reports and which are giving that sort of information to women who, in some instances, are frightened. How is that targeting happening?

Ms Janice Donlon

I might take that question first. What we have seen and through our communications unit in the HSE, is that women seek information about abortion services and crisis pregnancies primarily online, through a Google search. These rogue, disingenuous agencies are targeting women by increasing their spend on paid AdWords on Google. We in the HSE try to combat that by outbidding them in terms of search words. It is a constant battle. We are trying to ensure that our information about the funded services, the Positive Options information, comes up first on Google searches and that these rogue services are not the first result that somebody will see. I think in the past they may have taken out advertisements in the Golden Pages and the agency and the programme would have tried to combat that by taking out bigger advertisements. It is a matter of trying to keep up with them at all times.

Another issue is that they regularly change their names. While we may have been aware of some of them in the past, they have now changed their name so it is very hard to track. They change their locations. It is very difficult to deter women from a certain agency when we do not know where it is actually located. It is incredibly difficult and the services we fund, which see these women after they have been through traumatic experiences, would certainly let us know that women are traumatised. They do not want to go through a complaints procedure against these organisations. We have a complaints mechanism in place if a woman wants to go ahead in that regard. Often, the woman just wants to get the non-directive, non-judgmental counselling in order to get through her crisis and does not want to revisit a very difficult time.

We would absolutely welcome the regulation of counselling services. The counselling services we fund would also welcome it. Counselling in general is not regulated. There is no regulatory body over it. In the absence of regulation, what the HSE has done in terms of the crisis pregnancy counselling services is to provide training and support for counsellors in a non-regulated environment. We have robust service arrangements with all of the organisations and put funding into training for individual counsellors. They have access to supervision as well in terms of their counselling practice. In order to level the playing field in terms of transparency of crisis pregnancy services, I think regulation certainly will help.

What was the Deputy's previous question?

It was to do with the numbers. The number of women accessing abortion pills increases while the number travelling decreases, but the number of those accessing counselling remains low. I do not want to put words in Ms Donlon's mouth but, given that the services are very widely advertised and easily accessible for women and they are not accessing them, I am taking that as an indication that it would be reasonable to assume that women are happy with the choice they have made.

Ms Janice Donlon

Again, international evidence would concur that women do not tend to seek counselling post-abortion in great numbers. I think our numbers are reflective of that. We certainly want to ensure that women are aware of the services, that they are free and open to women who have had terminations not just recently but in the past as well. The services are available there. Certainly, we would not anticipate an increase in the numbers attending the services.

I thank Ms Donlon for her presentation. We are discussing socioeconomic status and disadvantage in the context of women and the choices they make. Looking at the Positive Options website and the clinics that provide counselling services - which the HSE funds - I counted 32 or 33 locations but Ms Donlon says it is 40 and I accept that. I did not look at the geographical spread in respect of them but I want to make a point about access to full information for all women across all centres in Ireland. Outside of the urban centres, it might be more difficult for women to access a crisis pregnancy counselling service. Would Ms Donlon comment on that? It makes it more difficult and therefore the question of socioeconomic and economic disadvantage applies very much more for people who are not near an urban centre where they have choices in the type of counselling received.

My second question is on the list of agencies under Positive Options, approximately one third of which are run by Anew and Cura. On their websites, both organisations state that they do not provide contact details for abortion clinics or abortion information services, but they will discuss. It was stated here that the legal framework for providing information on abortion requires that individuals must be given access to the information. If the only resource available to a poor woman is provided by Anew or Cura, which will not discuss abortion, why are they funded by the crisis pregnancy programme to provide one third of counselling services while failing to give women full access to all of the options they have? Does it not further disadvantage women who are socially and economically in a bottom bracket? While Anew or Cura will not provide the information women need on abortion, they will provide the name of a doctor or other service they can attend. Does it not compound their disadvantage and possibly even the delay in procuring an abortion? Women need and want to have access to abortion as early as possible but this seems to be an anomaly. Why does a State agency such as the crisis pregnancy programme fund services which will not provide the full information to women? They state on their website that they will discuss but not provide the information.

Ms Janice Donlon

We fund 15 services providing crisis pregnancy counselling, two of which, the Deputy is right to state, do not provide, due to their ethos, information on names and addresses of abortion clinics outside Ireland. What they absolutely will provide, however, is information on all three options. If a client attends and wants to discuss the option of abortion, they will discuss it. Also, as the Deputy has seen from their websites, the information is very clearly accessible as to what they will or will not provide. As such, the client is made aware before she attends whether she will be provided with information on abortion services. There is an element of choice for some women of attending a service that is not going to provide the information, or choosing another service. They also have in place, as stated in their service arrangements with the HSE, robust referral procedures so that, if a woman they are counselling seeks information on abortion and wants the names and addresses of clinics, she can be referred to her GP or another service provider.

The counselling services certainly report to us that they will support women through the option of abortion. The ethos of their services does not allow them to provide the names and addresses of the clinics. Women attend crisis pregnancy counselling for a number of reasons and make decisions on their choices around their crisis pregnancies. As our research shows, 73% of women choose to parent and many of these organisations support women through that parenting. Even after the baby is born, they assist them with supports for new mothers. Certainly, there is a role for the services in that regard. Ultimately, the choice is for the woman as to which service she attends. I take the Deputy's point about a rural or an urban spread of counselling services.

It is also the point that one third of all the counselling services the programme funds are represented by these agencies which say they do not talk about abortion. Is that not an anomaly given the role of the crisis pregnancy programme? It funds counselling services that look at all three options, namely parenting, adoption and abortion, but one third of services, whether in rural or urban Ireland and notwithstanding the socio-economic point I made, will not talk to a woman unless she says, "I need to talk about abortion", at which point they will provide a list of doctors who will discuss it. Why would the HSE fund those agencies to provide one third of services?

Ms Janice Donlon

The counsellors who work in these services will absolutely support a woman who is exploring the option of abortion. What the ethos of their organisations does not allow them to do is provide the names and addresses of the clinics in England or elsewhere. Absolutely, she can be supported through that. They provide post-abortion counselling also for clients who have had abortions. Certainly, the individual counsellors are there to support women. Equally, the information is available to potential clients on whether they choose to attend that service or not. Certainly, we understand the point about the regional spread of these services. As Ms Deely mentioned, we are looking to develop a national telephone counselling service which we hope will help to open access to all services to individuals around the country who may find it difficult currently to attend a face-to-face counselling session due to geography, social circumstances and so on. Hopefully, that will open counselling services to more women.

I apologise if the following has been asked in my absence. What is the policy in the crisis agencies funded by the HSE when a woman tells a counsellor that she has taken illegal abortion pills obtained online? Are women being advised to say nothing or that they had a miscarriage or to tell their doctors the truth?

I spoke to a girl this morning who travelled to Liverpool last year to have an abortion. She told me how she was surprised to find HSE branded leaflets in the waiting room of the BPAS clinic. Who makes or writes these leaflets and who pays for them to be printed and sent to the UK? Is there a significant level of hypocrisy in printing these leaflets and distributing them across the water? Is the HSE aware of these leaflets being sent further afield than the UK, i.e. to other European countries to which, because of cheaper flights or whatever, there is evidence that people are travelling?

The lack of contraception in crisis pregnancies was raised earlier. People may not have the means or capacity to access contraception following abortions. Does the HSE's programme have any mechanism dedicated to dealing with sexually transmitted infections? Its title refers to "sexual health and crisis pregnancy".

Ms Helen Deely

I will take the last question on contraception first. According to a general population survey of 2010, which looked at the cost and usage of contraception, the cost of contraception was not found to be an issue for most people. Only 18% of respondents without a medical card found that it was an issue for them.

Ms Helen Deely

Yes.

Which is one fifth.

Ms Helen Deely

Yes, of people without a medical card. They found it was an issue.

That is fairly high, is it not?

Ms Helen Deely

It is 18%.

That is one fifth of the cohort that does not have a medical card finding it an issue. I see that as high, not low. I suppose it depends what way one looks at it.

Ms Helen Deely

Okay. On access to contraception, we support the ICGP on training on long-acting reversible contraceptives and have done so for a number of years. We also run campaigns to encourage the consistent use of contraception by women and young men. Our programme extended its brief two years ago when the sexual health strategy was published and we now have responsibility for implementing that strategy within the HSE. As such, our mandate now extends beyond crisis pregnancy to looking at sexual health.

Ms Janice Donlon

Where a client has taken an abortion pill, the primary concern of the counsellor is the care of the client.

It involves the client being assured that if she is having a medical problem, she can attend a hospital or GP service. If she is having a complication after taking the abortion pill, she is encouraged to attend the service and to tell someone she has taken the abortion pill and not hide it and try to pretend she has had a miscarriage or anything else. Disclosing that she has taken the abortion pill would certainly be encouraged by the counsellors, who, through the services we fund, would have received training, support and guidance in this area. It is an incredibly difficult area. It is a difficult area for the client and it is also an incredibly difficult area for the counsellor in terms of the legislation and the potential penalties for both. The priority is that the client is not fearful of attending a medical service should she have a complication or of attending a counselling service should she need that support.

The Deputy is probably referencing the abortion aftercare leaflets that are available in British Pregnancy Advisory Service, BPAS, clinics. We have a relationship in terms of sending our information to abortion clinics in the UK and the Netherlands. The reason we do that is because we want Irish women who attend these services and have an abortion to be aware of the State-funded services that are available to them on their return so I think it is entirely appropriate that the HSE would send our materials to these services, which we know women attend. We gather the data on an annual basis from the Netherlands and the UK and we know women are attending these services so we highlight to women that they can attend free counselling and access a free post-abortion medical check up and we will continue to do so.

I was not suggesting that they thought it was inappropriate. I was really making the point that I believe people need to be made aware that as well as farming out our problem to other countries, we are sending information over for our women to get over there.

We cannot expect Ms Donlon to comment on that.

I thank the witnesses for their presentations. Many of the questions I had have been answered so I have only two brief questions. I apologise for interrupting Deputy Fitzpatrick earlier on but I think it is a point that is worth noting. I probably should have waited my turn. In respect of adoption and whether it is decreasing or not, when we are having any conversation about women and the choices they have made, we need to look at it in the context of our history, the number of women we locked away and put in mother and baby homes and the number of illegal adoptions that took place in this country. If the research is not there, I am sure it would factor in along the way if research was ever done. It is important to say this because I do not think any of us would ever want to advocate that we want to go back to those figures. It just involves being mindful of those women and the fact that they probably would have chosen to rear their children had they been given the support to do so. That was the point I was trying to make.

In respect of socio-economic matters, I know from throughout my time supporting mothers who already have children, particularly if they are at risk of homelessness or are in addiction, that they are always very cautious of seeking help, particularly from State bodies. There is some distrust there sometimes. If somebody is experiencing addiction, how does the counselling operate in this scenarios? Women are sometimes petrified of being judged as mothers. They are worried that the children they already have might be taken off them if they raise the reason that a pregnancy is such a crisis. How do the witnesses deal with that and have they come up against it? Is there a cohort of women who do not access services because it is a State organisation? How can we address that? A point was made that socio-economic inequality exists in respect of being able to travel for abortion with poorer women being more likely to turn to the abortion pill. What is the witnesses' take on the overall impact of the socio-economic status or circumstances of a woman on her options in a crisis pregnancy?

Ms Janice Donlon

In terms of a client who may come with additional needs in terms of addiction, the crisis pregnancy counselling services are open to these women but the Senator is right. They often do not see themselves going to those kind of services. They may be fearful and may not feel that it is for them. They may feel there is another agenda there, whatever that might be. What we have done in the HSE is to provide training and support to services that are already engaged with these women, such as addiction services, so we would fund NUI Maynooth to provide master classes on particular topics around crisis pregnancy. These classes are open to anybody who works in the HSE or any of the funded services. More recently, people from a vast array of services have been attending those master classes so addiction counsellors, public health nurses and people from other areas of the HSE would attend them. It is about providing them with the knowledge and information to be able to go back and support their clients. Equally, a counsellor will see a client with any additional needs but may not always be able to support her fully and may then need to refer her back for additional support.

The second question concerned-----

It concerned the impact of socio-economic circumstances on a woman's options. All options might not be available to her given the circumstances in which she finds herself. It is probably quite a broad question. It has been said that there are as many reasons as there are pregnancies so it is such a wide range to capture. We think we have options and a choice in those options but sometimes because of our socio-economic disadvantage or circumstances, even our options are limited. Is that the case?

Ms Janice Donlon

I think the Senator is right. The options are more limited for those with lower financial means, those in situations involving domestic violence and those facing a multitude of situations whereby they are unable to make the choices their counterparts with financial means are able to make. If we take the example of asylum seekers in particular, they are restricted in terms of their economic and social ability and the procedure they must go through should they choose the option of abortion in terms of travelling outside the State for an abortion. They can be insurmountable to many women in terms of going through with the option they have chosen so there are a range of additional issues that influence a woman's ability to make a decision and follow through with that decision.

Some research has been done on adoption. The biggest contributor to the fall in adoption rates was when the State introduced payments to women who were initially called unmarried mothers that became payments which allowed people to parent alone so that women did not have to continue with a pregnancy and then give their children up, but had the right to raise their own children and had the economic basis to do so. The evidence would support that view. I thank the witnesses for coming before the committee. One of the excellent parts of today's discussion has been the highlighting of the rogue agencies that are out there and the imperative on us as legislators to deal with that. It relates to the point made by Niall Behan earlier that they are the ones that are not regulated.

I do not know how to react to this presentation because I am torn, on the one hand, by trying to get the information out there that despite criminalisation, there are State-provided services for people with crisis pregnancies before and after an abortion which women in Ireland might need tonight. That is not well known so that is a message we need to get out. However, on the other hand, is it not an indication of our utter sickening and depressing hypocrisy that we dance around this issue, provide State services, give a constitutional right to access a service in another state, even send the leaflets over and look after women when they come back, but we have no abortion in Ireland? That is demoralising. The witnesses are the ones who are implementing that farce.

I do not know if they can comment on it. I am trying to address the Regulation of Information (Services Outside the State for Termination of Pregnancies) Act and the difficulties it causes. We have had a lot of testimony about the break in the continuum of care. Have the HSE's service providers or the agencies it funds highlighted any particular problems? I am thinking of the comments made by the IFPA, in particular, about deaf women. Somebody might be given information by a service but how does a deaf person ring a clinic in England and make the appointment? Is that not a double discriminator? How would that be addressed? What are the problems in terms of that legislation? Other contributors have said contraceptive prevalence is actually the key determinant of lowering abortion rates. Deputy O'Connell made a point earlier about universal access to contraception. Is that something the HSE has done research on or costed? It would be of huge benefit to people.

Ms Janice Donlon

I will take the first question on the Regulation of Information (Services Outside the State for Termination of Pregnancies) Act. We acknowledged in the presentation that the Act is outdated given the current technology available to people and the access to information. That is one aspect of it. The other aspect the services report to us is that clients are often very surprised that when they attend a counselling service they can be given a list of names and addresses but they cannot be advised on which service might be best for them. They cannot be referred to a service. Their GP cannot refer them to a service and they are left alone with their list of services to contact and have to make the arrangements themselves. The counsellor cannot support them through that element of the decision. That is more difficult for some women than for others. It has been highlighted that women with additional needs or financial difficulties are presented with more challenges in making those arrangements and carrying out their decision.

Ms Helen Deely

I can give the committee some statistics on contraception from the ICCP study from 2003 to 2010. It tells us that even though older age groups are less likely to use contraceptives consistently every time they have sex, there is an increase in contraceptive use across all age groups. Condom use increased from 57% in 2003 to 62% in 2010. Use of the pill increased from 39% to 43% in those years. There was an increase in IUDs from 6% to 11%. Consistent use of contraception is lower in the older age group. That has to do with the fact that sometimes women do not believe they are fertile or are ambivalent towards becoming pregnant or would not view an unplanned pregnancy as a crisis. Increasing access to contraception outside of medical card holders would be a policy decision. There would need to be information and education campaigns on it in terms of consistent and proper use of contraceptives. In our programme, we run campaigns to promote consistent use of contraceptives. We fund the ICGP to claim for long-acting reversible contraceptives, LARC. We also fund a national condom distribution service that distributes condoms to groups working with those at risk of HIV or STIs.

I welcome our guests and thank them. Ms Donlon spoke about the disingenuous behaviour of some non-State funded agencies. We are all agreed, I am sure, that anything dishonest, underhand or coercive in pregnancy counselling is entirely wrong. Deputy Fitzpatrick and Senator Mullen drew attention in an earlier session to dangerous advice given by the IFPA and others which was the subject of an exposé in the Irish Independent around 2012. The Chairman asked for that to be clarified. When the witnesses saw that report, did they do any due diligence checks to see if there was any basis to those disturbing claims? Did the HSE have any contact with the IFPA and other agencies involved about that?

Ms Janice Donlon

Following those allegations of improper information provision, a full audit was carried out on behalf of the HSE. It was an independent audit with an independent chair, Brigid McManus, previously of the Department of Education and Skills. That was carried out in light of the allegations. A desktop analysis was done on a number of services and six, including the IFPA, were chosen for an in-depth, face-to-face audit by the quality and improvement division of the HSE. It was a robust audit on policies, procedures, guidelines and protocols. It involved in-depth interviews with staff members. The audit made 11 recommendations, all of which have been fully implemented. The majority of those recommendations were around improving the policies and procedures that were available in the counselling services. We and the HSE took the broad view that we were here to support the services in terms of our funding and we supported them through additional training, updating our practice guide, our training manual and by helping them to improve their policies and procedures where there was a lack of available information highlighted by the audit. We also implemented a quality framework with all services. All services are signed up to a quality framework that assesses against national standards for crisis pregnancy counselling. These national standards are based on the HIQA Safer Better Healthcare standards. All services now have that implemented within their crisis pregnancy counselling service.

How many did Ms Donlon say? Was it six?

Ms Janice Donlon

An in -depth audit was carried out on six.

How many altogether?

Ms Janice Donlon

There were 16 services at that point in time that were funded through the programme.

Were they all-----

Ms Janice Donlon

There was a desktop analysis of the other services and an audit of six. Those six were services against which allegations were made. They were the six chosen for an in-depth analysis.

Should counsellors getting State funding be required to inform people of a possible risk to mental health? I think Ms Donlon used the word "advised". Should they not be required?

Ms Janice Donlon

Risk to mental health from what?

Ms Janice Donlon

The counsellor is not a medical professional. They do not have medical backgrounds. The counsellor is there to support a woman through her decision. If that decision is she wishes to have an abortion, she will be provided with evidence-based information on the abortion. The information that is provided is based on Royal College of Obstetricians and Gynaecologists guidelines. Equally, if the client has particular medical issues, including mental health issues, they should be referred on to her GP to provide her with evidence on risks and complications of the procedure.

I raised this in the Dáil on countless occasions at the time of the investigation and after the exposé. It was supposed to be an investigation first. Then the Minister for Health told me it was a report. Does Ms Donlon know if the gardaí were involved in any of the six services the HSE had to do an in-depth audit of?

Ms Helen Deely

The Garda carried out an investigation and a file was sent to the DPP. The DPP's decision was there was no case to answer.

I accept that but earlier it was suggested by previous guests that the gardaí were embarrassed to be investigating it.

This is not a matter for Ms Donlon. We have already addressed this.

I am just making the point that-----

The Deputy can say that but the witness does not have to comment.

She does not. I appreciate her honesty. I will continue.

In terms of the language used around a fatal foetal abnormality, I am sure that the witnesses are aware, and I do not suggest that they are not aware, that the HSE brought in new guidelines. Indeed, I introduced a Private Members' Bill, not that we wanted to lock anyone up or fine medics, but because we wanted more sanitised and less crude language used when a pregnant mother and her spouse, partner or whoever received the devastating diagnosis. How have the new guidelines been operated?

I was involved in the negotiations for the programme for Government and it was agreed that perinatal hospice services would be included. I ask the witnesses to comment on the two issues, please.

Ms Janice Donlon

Our remit, within the HSE, is around the provision of counselling services. We are separate in terms of maternity services provision.

In terms of the language used for a diagnosis of a fatal foetal abnormality or a life-limiting condition, the services that we fund have said to us that they use language that their clients are comfortable with. That is how they support their clients through this diagnosis.

The HSE brought in new guidelines about two years ago.

Ms Janice Donlon

Yes. I understand that through those guidelines, and bereavement care guidelines, the life-limiting condition terminology is used. In practice, the crisis pregnancy counselling services have told us that the language used in a counselling session is the language that the woman and her partner is comfortable with. It is good counselling practice to do so.

What about a perinatal hospice?

Ms Janice Donlon

I am not familiar with the initiative because it is not our area of expertise. I know that the bereavement care guidelines have been issued and are currently being implemented. However, the HSE is not part of that implementation.

I asked the question because I want a pregnant person to be offered a full suite of care initiatives and not abandoned. This morning I spoke to Mr. Jonathan Irwin, founder of the Jack and Jill Foundation. The foundation provides so much care and we salute them for doing so. I want people to be given options and told that there is some care when they receive the diagnosis, and I want that incorporated in advice given.

Ms Janice Donlon

Again, crisis pregnancy counsellors are not experts in maternity care. Information provided on the options available to women and their partners in this situation is best discussed in a maternity service that has expertise in the area.

I thank Deputy McGrath for his comments. I also thank Ms Donlon and Ms Deely for their attendance. The information that they have provided has been very helpful.

I propose that we adjourn the meeting. I will have no talk of any other business. I propose that we meet again next Wednesday on 22 November at 1.30 p.m. in public session.

The Chairman mentioned earlier that there would be a half an hour's discussion on an issue.

By all means. I would be delighted.

Next week at 1.30 p.m.

Will that be in private or in public?

The joint committee adjourned at 5.55 p.m. until 1.30 p.m. on Wednesday, 22 November 2017.