International Context: Dr. Patricia Lohr, British Pregnancy Advisory Service

We will now resume in public session. I welcome members and the viewers who are watching the proceedings of the Joint Oireachtas Committee on the Eighth Amendment of the Constitution. We will be holding two separate sessions this afternoon. In the first session, we will meet a representative from the British Pregnancy Advisory Service. In the second session, we will meet a representative from One Day More, the support group for parents who have received poor pre-natal prognoses. Before I introduce our witnesses, at the request of the broadcasting and recording services, members and visitors are asked to turn off their mobile phones or switch them to aeroplane mode. On behalf of the committee, I extend a warm welcome to our first witness, Dr. Patricia Lohr, medical director of the British Pregnancy Advisory Service. I must advise Dr. Lohr on the matter of privilege before we begin our proceedings proper.

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 nor 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 Houses or an official either by name or in such a way as to make him or her identifiable.

I now invite Dr. Lohr to make her presentation.

Dr. Patricia Lohr

Thank you. I have a prepared statement and afterwards I will be happy to take any questions members may have.

My name is Patricia Lohr. I am the medical director of the British Pregnancy Advisory Service, BPAS. I trained in obstetrics and gynaecology at the Harbor-UCLA medical centre in Torrance, California. I followed this with a fellowship in family planning and contraception research and a masters degree in public health at the University of Pittsburgh. I am a fellow of the American Congress of Obstetricians and Gynecologists and of the US Society of Family Planning. I have an honorary fellowship form the UK Faculty of Sexual and Reproductive Healthcare. During my career, I have focused on the delivery of evidence based abortion care and family planning, including developing protocols, training doctors and nurses, providing services and conducting research. I am currently a member of the Royal College of Obstetricians and Gynaecologists, RCOG, abortion task force for which I am currently working on post-graduate curriculum development and a pathway for the care of women needing abortions who are medically complex. I am a founding member and the treasurer of the British Society of Abortion Care Providers which is an RCOG specialist society and currently sit on the National Institute for Health and Care Excellence, NICE, termination of pregnancy guideline committee which has been tasked with development a new evidence-based guideline for England. I was a member of the development group that wrote the last RCOG guidance on abortion care and have contributed to other national and international guidelines on contraception.

BPAS is a charity which was established in 1968 to provide not-for-profit abortion care that the National Health Service, NHS, at the time either could not or would not provide. Today, we provide contraception, pregnancy options counselling, abortion care and miscarriage management from more than 40 centres across England, Wales and Scotland. As part of our charitable remit, we also provide education on the causes and consequences of unwanted pregnancy and our nurses visit schools and colleges to provide information about contraception and fertility to young people to empower them with the knowledge to make their own reproductive decisions.

The majority of our services are provided under contract to the NHS, meaning the vast majority of women we see do not pay for their treatment. That now includes women from Northern Ireland, whose care is funded by the UK government and will be managed through a central booking service. The remainder are fee paying patients who overwhelmingly come from the Republic of Ireland. We provide care at or below cost to women from Ireland in recognition of the financial challenges they have already faced in reaching the UK and we have a policy of never turning any woman away based on her ability to pay.

While it is true that I am someone who believes strongly that abortion care is a fundamental part of women's reproductive health care, I am here today to provide this committee with factual information on the experience of Irish women who travel to the UK, how their abortion care is provided and the limitations of the current framework for providing the highest standard of care. As an organisation, we have no financial interest in Ireland changing its laws and will continue to provide not-for-profit services to Irish women if they cannot access abortion at home. In the UK, with the exception of Northern Ireland, a woman can access lawful abortion if she meets the terms of the Abortion Act 1967 and two doctors agree, in good faith, that she does so. Any abortion outside of that framework falls under the Offences Against the Person Act 1861 and carries the threat of life in prison for the woman and anyone who helps her. All abortions must be performed in NHS hospitals or at specifically licensed premises such as those run by BPAS.

The majority of abortions are performed under ground C, which stipulates that the pregnancy has not exceeded its 24th week and that the continuation of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman. A smaller number are performed under ground E, namely, that if the pregnancy continued the baby would be born with a serious mental or physical disability. The vast majority of abortions, 92% last year, were carried out at under 13 weeks' gestation and 81% were carried out at under ten weeks. This is in no small part due to the increasing availability of medical abortion, which can be offered at some of the earliest gestations. Medical abortion involves taking two medications, mifepristone and misoprostol, ideally 24 to 48 hours apart for maximum efficacy. Medical abortions account for more than 60% of the total number of abortions performed, although this method becomes less acceptable to women as gestational age advances.

Small numbers of abortions are performed after 20 weeks' gestation and account for approximately 1% of the total number of abortions performed. Some of these will be for reasons of foetal anomaly which are not detected until the scan at 20 weeks. Others will involve late detection of pregnancy, sometimes as a result of contraceptive use which has disturbed bleeding patterns, so that a missed period is not interpreted as a potential marker of pregnancy. While teenage pregnancies have declined dramatically over the past decade, a younger woman with an unwanted pregnancy is proportionately more likely to need a later abortion. This may be because a pregnancy was not suspected or because she has felt unable to confide in anyone about her circumstances.

In terms of the overall picture of abortion within the UK, the rate is stable at around 16 per 1,000 women. This rate is largely unchanged since the late 1990s. The age profile at which women have abortions is changing, however. The teenage pregnancy rate has decreased dramatically and more older women are requesting abortion care. At BPAS, we see more women over the age of 35 requesting abortion than women under 20. It is estimated that one in three women will need an abortion in their lifetimes and that one in five pregnancies end in abortion.

The abortion rate in England and Wales is similar to that in other socially and economically comparable countries such as France and Sweden. The UK is not an outlier in regard to its abortion rate. There is, in any event, no evidence that laws influence the numbers of abortions. The respected Guttmacher Institute has shown, for example, that the rate of abortion in countries with highly restrictive abortion laws is comparable with that in countries with more liberal frameworks.

To address specifically the issue of women from Ireland needing abortion care, last year 3,625 women were recorded in the annual abortion statistics produced by the Department of Health in England as having given an Irish address when they presented for treatment.

Over the past ten years, the number of women giving Irish addresses has fallen from 4,600 in 2008. This decline may be underpinned by a number of factors, including better access to contraceptive services and emergency contraception, increased access to abortion medication and increased awareness that free treatment can be obtained with a UK address. A paper published in the British Journal of Obstetrics and Gynaecology in July reported that between January 2010 and December 2015, some 5,650 women from Ireland and Northern Ireland contacted one online provider alone to request medical termination of pregnancy.

BPAS has been providing abortion care to women from Ireland since 1968. There is little difference between the reasons women from Ireland present and the reasons women from the UK present; they are diverse and multifaceted. They may involve financial hardship, knowing one's family is complete, inadequate partner or family support, domestic violence or simply a woman feeling she is not in a position to care for a baby at that point in her life. While some abortions take place of pregnancies that were planned and wanted, such as those for foetal anomaly, the majority of the women we see were trying to avoid pregnancy when they conceived. In fact, the majority of women from Ireland we treat were using some form of contraception when they conceived. We undertook an analysis of 2,703 women from Ireland who were treated at BPAS over a four-year period and found the following: 3% were using a method such as an intrauterine contraceptive, implant or sterilisation; 29% were using injections, oral contraceptives, such as the pill, a patch or a ring; and almost 50% were using condoms, diaphragms or fertility awareness-based methods. Only 20% were not using any method at all at the time they conceived. Of Irish women who receive abortion care in the UK, 70% are married or with a partner, and nearly half have already had at least one previous birth, meaning they are already mothers. All this is in keeping with information we have for women from the UK seeking abortion.

What is different for Irish women? As previously noted, medical abortion now accounts for the majority of early terminations in the UK. Many women prefer it as it is akin to a natural miscarriage, they can avoid an anaesthetic and they can be at home when the pregnancy passes. In contrast, the majority of early abortions provided for Irish women are performed surgically - 71%, compared to 28% for women resident in England and Wales. This is because for financial and practical reasons, many women travelling from Ireland often aim to fly in and out of the UK within a day and, as medical abortion involves leaving the clinic after taking the second set of medication and going home to pass the pregnancy, it is not clinically optimal for this to happen on the way to the airport or the flight home. Effectively, this means that women from Ireland are in all practical senses denied a choice of abortion method.

Irish women also have abortions at slightly later gestations than women having abortions who are resident in England and Wales. The vast majority, 81%, of residents of England and Wales present between three and nine weeks' gestation, compared to 69% of women from the Republic of Ireland. At ten to 12 weeks' gestation, 11% of residents from England and Wales and 16% from the Republic of Ireland present. At the latest gestational bracket, 20 weeks or over, 2% of women resident in England or Wales present, compared to 3.2% of women resident in the Republic of Ireland. Nearly a third of abortions, 31%, for women from the Republic of Ireland are performed at ten weeks or over, compared to 20% for women resident in England and Wales. Abortion is an extremely safe procedure, but the earlier in pregnancy it is performed the better for women's physical and mental well-being. Reasons for later presentation include the time it takes to organise travel and make logistical arrangements, particularly for those with work and child care commitments.

All women who receive NHS-funded treatment at BPAS are entitled to contraception counselling. They can choose from the full range of methods available and, if they wish, can leave with the method of their choice. Provision of contraception at the time of abortion has several advantages - the woman is known not to be pregnant, and it confers immediate protection against pregnancy and, with regard to implants and intrauterine contraception, increases the likelihood she will receive the method compared to women who must return to undergo insertion at a later date. Irish women who attend BPAS are also offered contraceptive counselling, and the overwhelming majority take it up. However, because of the costs associated with receiving their chosen method, as well as the logistics of integrating contraception care with travel, in our analysis only 31% chose to receive their preferred method from BPAS. This is compared to 85% of women we see who are funded for their contraception care. This means that an important opportunity to enable women to make a choice about contraception and receive that method is lost. It is possible women visit their general practitioner or family planning clinic on return to Ireland and receive the method they have chosen, but we have no way of establishing this or following it up.

Regarding post-abortion care, all women undergoing an abortion at BPAS have access to a 24-hour telephone support line. While follow-up appointments are only provided to those women who want them, all women know they can contact the clinic which treated them and return for a check-up or discuss their concerns at any time. Women from the Republic of Ireland too can access the telephone support line, but if they have any concerns that need in-person care they will typically access local services, which can present its own problems in view of the stigma and secrecy that continues to surround travel for abortion.

Complications from abortion are uncommon, and serious complications are rare. In its paper, Best Practice in Comprehensive Abortion Care, the RCOG recommended that women be advised of the following risks. Failure occurs in one to two in 100 cases of either medical or surgical abortion. Fewer than two in 100 surgical abortions and approximately five in 100 medical abortions are incomplete and need some form of intervention in order to complete the procedure. The following complications may occur. Blood loss needing transfusion occurs in fewer than one in 1,000 cases in the first trimester, rising to approximately four in 1,000 at 20 weeks' gestation or more. Uterine rupture with second trimester medical abortion occurs in fewer than one in 1,000 cases. With surgical abortion there is a similar low risk of cervical trauma - fewer than one in 100 overall, but the risk is lower in the first trimester - or of uterine perforation, which occurs in approximately one to four cases per 1,000, and again the risk is lower in the first trimester. It is sometimes necessary to provide further treatment for complications such as a blood transfusion, laparoscopy, laparotomy and, very rarely, hysterectomy. An upper genital tract infection can occur after abortion, with varying degrees of severity, and is most likely associated with pre-existing infection.

Regarding the mental health impact of abortion, the risk of developing mental health problems is the same for a woman facing an unwanted pregnancy whether she has an abortion or goes on to have the baby. While most women will not require further counselling, post-abortion counselling is available to all women who have had an abortion at BPAS, either over the phone or in person. Needless to say, for women travelling from Ireland the option of in-person counselling at BPAS would be difficult, although this is available through some of the agencies in Ireland. We can advise women undergoing abortion for foetal anomaly on the transport of foetal remains for autopsy, burial or cremation. Women from Ireland must take the foetal remains home themselves and find a carrier that will accept the remains on board. If they want an autopsy or other testing for the foetal remains, this would be self-funded.

What can Ireland learn from the UK? If Ireland overhauls its abortion laws, which is certainly not for me to prejudge, it would do well to avoid some of the pitfalls and problems that the UK framework presents. The Abortion Act 1967 was passed at a time when abortion provision was almost entirely surgical and when all surgical procedures were riskier than they are today. Against this backdrop, it is unsurprising that politicians stipulated that all procedures should be carried out in an NHS hospital or in specific premises licensed by the Secretary of State for Health and that all such procedures should be performed by a doctor.

Few could have imagined in 1967 that early abortion could be safely provided using medication. Our laws have prevented the provision of early medical abortion in line with guidance from the World Health Organization, which recommends that women should be able to use misoprostol at home once lawfully prescribed. This means that women can time the passing of their pregnancy and do not have to risk bleeding or miscarriage on the way home, nor do they have to attend multiple appointments.

I spoke earlier about the number of women from Ireland using online abortion services and it may surprise the committee to know that women living in areas of the UK where funded, legal abortion is available are also turning online. Over a four month period more than 500 women in England, Wales and Scotland requested help from Women on Web, one of the online medication abortion providers. For some women, the multiple appointments, sometimes considerable distances from where they live, were an absolute impediment to accessing lawful care.

Our laws have also prevented the full development of nurse and midwife-led services that are now the standard in other areas of care like colposcopy. Nurses are lawfully able to provide surgical and medical miscarriage management using the same techniques as an early termination but are prohibited from providing that service to women needing an abortion. With regard to premises, there is no reason why early abortion, whether by vacuum aspiration or pills, could not be safely provided from a GP surgery but again our laws make that all but impossible.

Keeping abortion within the criminal law, as opposed to regulated by health care law like all other procedures, can be hugely stigmatising. Canada and parts of Australia have opted for the decriminalisation of abortion, regulating it through health care law and professional standards. There is no evidence that abortion is more widely used or indeed more available as a result. We do not need a criminal code to impose a time limit for example, but keeping the procedure outwith the criminal law and the subject of professional guidance and health care regulation means that lawful abortion care can be provided in accordance with the highest clinical standards and best practice. Ireland has the opportunity to create a humane abortion framework that is fit for the 21st century. I hope the information that I have provided to the committee is helpful for this discussion and I am happy to take any questions that members may have.

I thank Dr. Lohr. The four main speakers are Deputies Catherine Murphy, Bernard Durkan, Jan O'Sullivan and Lisa Chambers. Each has ten minutes.

I will divide my time between this and the next session. Perhaps the Chairman will tell me when five minutes is up.

Certainly.

It is very clear. Dr. Lohr would not describe the UK system as an on-demand system given that women have to go through a rigorous regime of meeting with two medics before an abortion can take place.

Dr. Patricia Lohr

That is correct. Two doctors have to sign a form called an HSA1 form after reviewing the circumstances of the woman who is requesting the abortion, to determine whether she fits one of the five grounds of the Act.

Dr. Lohr has spoken of how the criminalisation is done differently in this area. What information does Dr. Lohr have on the impact this has had in respect of medical care and the medical profession in the UK, given that it remains in the background?

Dr. Patricia Lohr

Knowing that abortion sits within a criminal code and that a person could potentially be prosecuted certainly has a chilling effect on doctors and nurses who might be interested in entering this field. I believe it is a barrier to individuals engaging in the field of abortion provision. Many women are not aware that abortion sits within the criminal code, but it is the case that some women are aware and they are aware that they have to meet certain criteria in order to obtain a lawful abortion. I have been made aware of cases at the British Pregnancy Advisory Service where women have concealed the reasons why they are coming for the abortion because they were worried it would not meet the criteria. I will give the committee an example. A woman was experiencing extreme lower abdominal pain during her pregnancy, so much so that she felt she could not continue the pregnancy. She did not believe that this reason would meet the lawful criteria for an abortion. When she met with our doctors she told us a different reason for wanting to obtain an abortion, which did fit with the Act. It was ultimately discovered that this woman had an ectopic pregnancy and a diagnosis of ectopic pregnancy was delayed.

There are very few things now, thankfully, that lead to maternal mortality in this part of the world. Unrecognised ectopic pregnancy, however, is one of them. For some patients it has potentially devastating consequences. I have made reference to a paper that was published about women in the UK who have contacted Women on Web about obtaining abortion medications because they felt they could not leave the house, perhaps they had a controlling partner or it was a domestic violence situation, maybe they could not afford multiple visits to the clinic, etc. The framework within which those women have to obtain an abortion is a barrier.

In her opening statement Dr. Lohr spoke about the rate of abortion in countries with highly restrictive abortion laws is comparable with that in countries with more liberal frameworks. Dr. Lohr referenced that research. Some people in Ireland argue that by virtue of the fact Ireland has the eighth amendment in the Constitution - even though there are other amendments that permit travel and information - it has saved lives when a woman has completed the pregnancy and gone on to have the baby. Would Dr. Lohr's assessment be that this contradicts that argument?

I want to let Deputy Murphy know that if the witness responds to this query then the five minutes are up.

Dr. Patricia Lohr

Does the Chairman want me to respond?

Yes. I am just managing the time.

Dr. Patricia Lohr

Ireland is fortunate that it has a country nearby where women can pay for and obtain safe abortion care. In many parts of the world where abortion is illegal or highly restricted that is not the case and women turn to unsafe means to end their pregnancies. This is associated with a very high maternal mortality rate in those countries. In Ireland's case we see that women who are able to afford to travel are able to obtain safe abortion care but I am sure there will be a number of women who cannot afford to travel who go on to continue pregnancies here that they would otherwise have terminated had abortion been available in Ireland. As we are aware, more and more women are obtaining abortion medications online here. While that is not an inherently unsafe activity these women lack the follow-up and other services they may benefit from, such as early pregnancy diagnostic services.

I thank Dr. Lohr.

Does Deputy Durkan want to share his time between the two sessions also?

I will let the Deputy know when his five minutes is up.

I thank Dr. Lohr for coming before the committee and giving us her views. I have a couple of questions. What is the extent of the risk associated with ordinary, conventional birth and with abortion? Has Dr. Lohr compared the figures in the UK and how do they stack up?

To what extent is counselling that comes before, during or after the process of terminating a pregnancy available in the UK for women in Ireland who travel over to have a termination? Have the witnesses studied the statistics in other European countries? In some cases, there is a vastly different number of abortions per 1,000 in countries where abortion is permitted. Have the witnesses come to a conclusion as to why that might be? Switzerland and Sweden might be compared, since the rate in Sweden is approximately three times as high as Switzerland.

Dr. Patricia Lohr

The Deputy's first question was about the risk of birth compared to the risk of abortion.

In the course of an abortion compared to the course of a normal birth.

Dr. Patricia Lohr

We know from maternal mortality data that are collected in the UK that the risk of continuing a pregnancy to term and delivering a baby is higher than that of having an abortion at almost any gestational age in the first and second trimester. Giving birth has got safer in the UK in the last few years and having an abortion is extremely safe. The reports on maternal mortality for the triennium of 2006 to 2008, which the Royal College of Obstetricians and Gynaecologists, RCOG, refers to in its abortion guideline, state that 107 direct deaths were associated with pregnancy out of 2.29 million maternities, giving a rate of 11.39 per 100,000 maternities. In comparison, two abortion-related deaths were reported in that triennium, of 628,342 abortions, which works out to a rate of 0.32 deaths per 100,000 maternities. I looked at some of the reports published since. Maternal mortality at the time of birth has gone down somewhat and the rate of deaths from abortion has not increased.

The Deputy's second question was about counselling for women from Ireland. I can speak for the British Pregnancy Advisory Service, BPAS. We make our telephone counselling services available to women from Ireland. They could access in-person counselling with us if they so wished but that would mean coming back to the UK. We provide women with phone-based counselling, which many women prefer. They usually only need a few discussions but can have as many as they need.

The Deputy asked about the rate of abortions across European countries. I am not an epidemiologist but looking at where the UK sits in the list of European countries, which the Deputy might have been shown a slide of in an early presentation, we are comparable. Abortion may have a higher rate in some countries than others for various reasons, as variable as the reasons women choose abortion but they are typically and commonly related to the availability of contraceptive services so where contraceptive services are widely available and funded, we tend to see a lower abortion rate. One sometimes sees cases where abortion services are well-funded, for example, in the UK, where women still avail themselves of having an abortion when they feel the need to end a pregnancy by termination.

The Deputy's five minutes are up but he can have a point of clarification if he wishes.

We were given evidence to the effect that sepsis is very rare now. I do not necessarily agree with that. Does Dr. Lohr have any evidence either for or against it in cases of abortion or natural, normal births?

Dr. Patricia Lohr

Sepsis in abortion is extremely rare. Upper genital tract infection, treated with oral antibiotics, is reported variably in the studies and often depends on the diagnostic criteria used. Where the diagnostic criteria are very strict, for example in cases of fever and evidence of increased of white blood cell count, the rates are quite low. There are higher rates where diagnostic criteria are vague, somewhere around one in 100. Those are typically treated with oral antibiotics. They are not cases of sepsis. Cases of serious sepsis are extremely uncommon.

I will take the five minutes please.

I have to be strict on time because it is bad evening and the witness will have to get a flight. I am allowing enough time.

I thank Dr. Lohr for the information. She has given us many statistics, particularly about Irish women and that is useful to the committee. She says she is here to provide us with factual information about the experience of Irish women who travel to the UK. They say she has no financial interest in Ireland changing its laws. Will Dr. Lohr clarify that is the case so there is no misunderstanding?

Dr. Patricia Lohr

It is absolutely the case for me personally as well as for BPAS as an organisation.

I wanted that to be clear on the record. I will ask Dr. Lohr about the experience of Irish women. She has informed us of the care pathways that BPAS provides. There is an issue for Irish women with regard to where the role of BPAS ends in the care pathways, particularly with regard to contraception counselling post-abortion. What is the effect of that? We have had previous evidence that would suggest that post-abortion contraceptive advice reduces the recurrence of further abortions. Is there any factual evidence related to that? What are Dr. Lohr's own feelings about not being able to continue the care pathway for women who have come to her services from Ireland?

Dr. Patricia Lohr

The best evidence we have for the role of contraception in reducing subsequent unintended pregnancies is receipt of the method at the time of the abortion. A number of studies have been done, looking at different models of contraceptive counselling before the abortion. None of the variations, whether specialist counselling or dedicated counselling, has been associated with the reduction in subsequent unintended pregnancies or abortion, particularly in the long term. We know that when women receive the method and start it straight away, that is associated with reduced risk. The only way that can happen is if the contraceptive counselling happens before the abortion. Every woman in our service is asked whether she wishes to use a method of family planning. If she does, we engage her in a discussion about which method of contraception would be right for her and we aim to provide it at the time of the abortion so that she is immediately and optimally protected.

For women who come back to Ireland, Dr. Lohr would presumably agree that contraceptive advice she be available both before and afterwards.

Dr. Patricia Lohr

Yes.

Thanks. Dr. Lohr said that 92% of terminations in the British systems happen at under 13 weeks and 81% are at under ten weeks. She also said that the majority of Irish women have surgical procedures.

Dr. Patricia Lohr

Correct.

A reason she gave was the time that one needs to be there for the medical procedure. Is there also evidence from Dr. Lohr's work that there would be a delay which would be a factor for Irish women having the surgical procedure?

Dr. Patricia Lohr

As I said in my talk, women coming from the Republic of Ireland tend to present slightly later for abortion care than residents of the UK. Some women will have exceeded the gestational age for which they can have an early medical abortion procedure by the time they come into our clinic.

Various people have asked about floodgates. Does Dr. Lohr have any evidence that this floodgate opened, with dramatic increases, at any time since the British Act of 1967?

Dr. Patricia Lohr

I am not an epidemiologist but I will speak about the data as well as I understand it. Illegal abortions are very difficult to count. We do know a bit about women who presented to hospital, for example, after having obtained an unsafe abortion in the UK before the Act was passed. Once the Act was passed the numbers of women having abortion did not go up dramatically. I guess that is what the Deputy refers to as floodgates. What we do know and can see in statistics is that, as abortion services became more widely available and abortion became better funded, and women became aware that those services were available and were safe, they did avail of them. Now we see that the number of women accessing abortion has been very stable for several years.

I thank Dr. Lohr for her presentation and for coming before the committee to give evidence and answer questions.

Could Dr. Lohr please respond to the concern that there is a risk abortion will be used as a form of contraception? Could she please paint a picture of the reasons for different age groups of women obtaining abortion, for example, among women younger than 20, aged between 20 and 30 and those over 40? Are there different reasons in those age categories?

I was struck by Dr. Lohr's figures, that 71% of early abortions provided for Irish women are surgical compared with 28% for women resident in England and Wales. That was because the Irish women had to travel back and forth in one day. The medical abortion, the tablet, cannot be offered to them. Do women arrive at the clinic seeking a medical abortion, thinking that is what they will have but then hear that they cannot have that service but will have to have a surgical abortion?

It appears from Dr. Lohr's presentation that there are more risks associated with surgical abortions than with medical, for example, uterine rupture, bleeding and other complications. Would it be fair to say surgical abortions are more risky and that Irish women do not have the choice when they go to the UK but have to have more surgical than medical abortions?

Dr. Patricia Lohr

I will take the last question first, about the risks of surgical and medical abortions. Proportionally, early medical abortions have a slightly higher rate of complications than surgical abortions. It is the profile of the complications that differs. With a surgical abortion a woman runs a very low but present risk of cervical or uterine injury. The most common complications of medical abortion are relatively minor, for example, some retain tissue that might need an additional intervention, although the bleeding risks are certainly higher.

In response to the question of whether women come into our clinics looking for a medical abortion and we tell them they cannot have it because they are there only for a day, we always try to meet the woman's request with regard to the method of abortion. We would never prevent a woman having a certain form of abortion but we would talk with her about the process involved. We would be honest about the regimen for early medical abortion which typically occurs over two days. Under the law in England and Wales - now Scotland is different – a woman must come into the clinic to receive both sets of medications. We would describe the process to her and assess her medical eligibility for either regimen and would leave it to her to decide. For all intents and purposes, however, from a practical point of view, most women coming from Ireland need to come and go in the same day. They have already had to gather the funds to pay for the abortion and travel so to add an overnight stay and another day away from work or home is too difficult. That is why the majority of those women choose surgical procedures.

The Deputy asked about differing reasons for abortion at different ages. We do see differences. Teenagers, those younger than 20, are often unable to care for a child, they may still be in school and it is not optimal for them to have a child. Women in their 20s and 30s are often looking to delay childbirth. We have seen the age of first time motherhood has gone up in the UK, as in many countries. Women are delaying childbirth for several years and it is important to note that most women in the UK are using contraceptive methods but all contraceptive methods have a failure rate and in typical use the failure rate for example, of the oral contraceptive pill is approximately nine in 100. If a woman is trying to prevent pregnancy for ten or 15 years it is possible, even if she is using her contraceptive method absolutely the way it is supposed to be used, that she might experience a contraceptive failure and if she is not ready to parent she will seek an abortion. Older women typically have completed their childbearing, for example, they did not expect to be able to get pregnant. They already have children and are seeking termination often for those reasons.

The last question was about contraception and I have forgotten what the Deputy asked, I am so sorry.

I do not take this view but some of the criticisms levelled at the provision of services were that women will use abortion services as a form of contraception. I would like to hear Dr. Lohr's response to that.

Dr. Patricia Lohr

It is telling that most of the women we see were using a contraceptive method at the time that they conceived. They were not intending to become pregnant and were intending to use a method of contraception to prevent a pregnancy. On that basis I do not see evidence that women are using abortion as a method of contraception. It is a backup for when contraception fails, or in a very small number of cases, as I have described, there are foetal or sometimes even maternal indications to end the pregnancy.

I welcome Dr. Lohr from the British Pregnancy Advisory Service. The head of Dr. Lohr's organisation, Ann Furedi, recently spoke on television about how she feels that abortion should be available for sex selection, if a woman finds that she is expecting a baby girl but wanted a baby boy that should be grounds for an abortion. I think most people find it quite upsetting that anyone would think a baby's life should be ended simply because she is a girl. Does Dr. Lohr think that abortion should be allowed on grounds of gender so that a woman can abort a baby girl if she wants a boy instead? The name of the programme is "Loose Women". It is a daytime programme.

Dr. Patricia Lohr

I have not seen the programme.

Is Dr. Lohr familiar with the statement made on the programme?

Dr. Patricia Lohr

I am not familiar with the exact text of the statement. What she may have been clarifying is that abortion on gender grounds is not one of the five grounds for lawful abortion in the UK. A woman may present to us stating initially that she wants to have an abortion on the basis of foetal sex. If that were the only reason she put forward to have her abortion, we would not be able to perform that lawfully. If, however, a woman presented saying, "I know my pregnancy is - pick your foetal sex - and I am at risk of exclusion from my family, domestic violence, etc.,", there may, in fact, be lawful grounds because that might risk her physical or mental health.

My question was whether Dr. Lohr thought abortion should be allowed on the grounds of gender. What does she think? Her CEO seemed to think it should be one of the grounds. She also stated on the same programme when she was talking about sex selection that it should always be down to the woman to make the decision for herself because she will live with it.

Dr. Patricia Lohr

I absolutely do agree with the position that it is for the woman to decide when and whether she is ready to parent or have a child and put it up for adoption.

I am talking about a boy or a girl. I am talking about gender selection.

Dr. Patricia Lohr

My point is that I feel that decisions about whether to continue a pregnancy should sit with the woman herself. As a doctor and knowing the risks of continuing an unwanted pregnancy, I cannot imagine compelling a woman to have and continue a pregnancy for which she is unprepared.

On the same programme, Dr. Lohr's boss said she thinks the current time limit in England of 24 weeks, or six months, should be dropped. Most people would be horrified at this thought which suggests the life of a baby can be ended so easily. There was no question of attempts being made to save the baby's life, just that abortion should be available after six months. Currently, English law allows an abortion up to birth if a baby has a disability like Down's syndrome. The members of the committee are already familiar with the frightening statistic that 90% of babies diagnosed with Down's syndrome in the womb are aborted. How many abortions have been carried out in BPAS clinics where the reason given was that the baby had a disability? Have any of these abortions involved babies diagnosed with Down's syndrome?

Dr. Patricia Lohr

I will be honest and say that I do not have the numbers with me of women that we treated with foetal anomaly but I can certainly provide that to the committee at some later time. I can also try to get the information about the indications for those terminations in cases of anomaly.

Dr. Lohr stated earlier that abortion is an extremely safe procedure but the earlier in the pregnancy it is performed, the better it is for the woman's physical well-being. I cannot understand how an organisation with more than 40 locations in the UK has not been able to come here and provide me with the two answers I seek. I asked how many abortions had been carried out in BPAS clinics. I am not asking for any personal information. I am trying to give people here a picture of what kind of an organisation or charity Dr. Lohr is involved with. It is horrifying that the CEO of the charity is encouraging gender selection. I said it here a few weeks ago and people were nearly laughing. That a charity in the UK is looking at the selection of genders is something I cannot understand.

I believe very strongly that we trust women. This is something I have also heard members of Dr. Lohr's organisation saying. If one trusts women, one must also trust them with full information about abortion including the fact that the baby's heart starts to beat at just 21 days in the womb and the fact that one in five pregnancies in England and Wales ends in abortion. The committee is tasked with looking at the impact of the eighth amendment in Ireland. This means undertaking to ensure that the public is fully informed of the development of a baby in the womb and how the eighth amendment is responsible for saving tens of thousands of lives in Ireland. If we are really going to trust women, does it mean we must run a nationwide education programme on all the good things the eighth amendment has done, the remarkable development of an unborn child and the fact that in England and Wales, over 190,000 babies lose their lives to abortion every year?

Dr. Patricia Lohr

It is not for me to say what sort of nationwide educational programmes there should be in this country if and when it chooses to change the law. I am not actually sure how to answer that question. I do not feel it is not in my remit, actually.

Dr. Lohr stated earlier that she goes to schools and colleges. What does she encourage these schools and colleges to do apart from gender selections and increasing legal abortion from over six months? I am just asking a few simple questions. Earlier I thanked Dr. Lohr very much for coming in today. She had a good presentation. I am just very disappointed with the answers I am getting. I am actually getting no answers.

If there are points that need clarification by the witness or the lady to whom Deputy Fitzpatrick has referred and the information is not available today, it is perfectly fine to provide the information to the committee later and it will be put on the record at that point. Unless the Deputy wants Dr. Lohr to give information that is inaccurate------

-----the witness can have that opportunity, in fairness to her, if she wishes.

I spent a lot of time going through these questions and looking for answers. In fairness, I thank Dr. Lohr very much for coming here today but I am very disappointed. This is a charity organisation and some of the statements and the things it is doing in the UK are out of proportion. I am disappointed that a representative has come over here but cannot give me the answers.

Is there anything Dr. Lohr would like to say in response?

If Dr. Lohr gets the opportunity, I ask her to look at the programme "Loose Women" which is a daytime programme here which a lot of people watch. Dr. Lohr's CEO has-----

Does Dr. Lohr want to respond?

Dr. Patricia Lohr

As I said, I am sorry that the Deputy feels disappointed. Had I known that was a specific number the Deputy was interested in me having to hand on the day, I would have prepared and provided it for him. I am very happy to provide those statistics to the Deputy at a later time.

I thank Dr. Lohr. I call Deputy Durkan. Sorry, he indicated and I have him down twice.

If the Chairman loves me that much that she wants me to go again, I will.

No. I call Deputy O'Connell. Sorry, I am obviously losing my mind.

I apologise that I had to leave the room for something. If I repeat something that was asked already, ignore me. I can look back at the record. Deputy Durkan touched on the rate of termination in the UK. I was sourcing some documents about the rate in the Netherlands which used to be the lowest but which has risen slightly in recent years. Dr. Lohr quoted a figure of 16 per 1,000 and I think the Netherlands stands at approximately 8.6 per 1,000. Some sources attribute that to Irish people travelling there. The Netherlands, like the UK, has quite a high number of Irish women who travel there for termination. As part of the continuing development of abortion services, has the UK done anything to try to reduce its rate? In Holland, they have a non-moralistic treatment of teenagers with education and access to contraception and so on. Can Dr. Lohr outline those things?

Ground E in the 1967 Act was quoted by Dr. Lohr who said it was for the case of a baby with a serious mental or physical disability? How is "serious" defined? On occasion, people here have thrown out the term "cleft palate", but from listening to the experts it is often a combination of conditions. It is not simply the case that a child has Down's syndrome.

It might be a child who has Down's syndrome coupled with kidney problems, a heart defect and so on. Perhaps the witness would elaborate on that issue. In regard to the limitations of the UK system around the abortion pill, why has nobody in the UK Parliament brought forward a measure to try to change that position? What are the barriers to it in a country that would be seen to have a liberal approach? Why has the United Kingdom as a country not done anything to date to address this issue?

Dr. Lohr referred in her opening statement to never turning anybody away. What does that mean? Does it mean that no woman is turned away when she makes contact by phone or when she lands on the doorstep? I am thinking in this regard about women who are being prevented from travel. Why in her view was the British Pregnancy Advisory Service, BPAS, set up to provide abortion services rather than this service being provided by the UK maternity hospitals under the National Health Service? The evidence suggests that reducing barriers to access to contraception tends to reduce abortion rates because of the reduction in unplanned pregnancies. As contraception is free in the UK, perhaps Dr. Lohr would elaborate on that point.

Deputy Louise O'Reilly took the Chair.

Dr. Patricia Lohr

Widespread and free availability of contraception is one of the most important contributors to reducing the risk of unintended pregnancy. As I have said, most women who present for abortions in the UK had not intended to become pregnant. Widespread availability of free contraception in family planning clinics has been important in the UK, as has been the concerted effort to reduce teenage pregnancies by ensuring that young people have available to them the full range of contraceptive methods, including national guidance which supports the use of long-acting methods of contraception in young people, which many doctors and nurses may have been reticent to provide in the past, as well as the education of young and older people about their bodies, the risks of becoming pregnant, when a woman can and cannot get pregnant and how one might prevent pregnancy. Last but not least, the availability of emergency contraception in order that women can prevent a pregnancy if they have had an episode of unintended, unprotected intercourse has also been hugely important. All of these initiatives have been undertaken to try to reduce the risk of unintended pregnancy.

As discussed, no contraceptive method is perfect and in typical use, the failure rates are relatively high, even with what most people might consider to be some of the more effective methods such as the injectable or oral contraceptive pill. There is a finite degree to which one can prevent the need for abortion through access to contraception or sex and relationship education. As we know, and as already referenced today, a small number of abortions are for pregnancies which are very much wanted but because the woman has a medical condition it is unsafe for her to continue to the pregnancy or, as described, there is a foetal anomaly which is an indication for a termination.

Deputy O'Connell asked how ground E was defined. As with all of the grounds for abortion in the UK, it is up to a doctor to determine whether the woman's presentation meets the ground of the Act. There is language in the Act, and in particular ground E, that describes foetal anomaly, to which a doctor may refer but we do not, for example, have a list of foetal anomalies which meet those criteria. I agree with the Deputy that doctors look to the whole picture, particularly in cases where the pregnancy is less than 24 weeks. It may be the case that some terminations may be performed later, for example, in cases of chromosomal abnormality, but the woman would also qualify for an abortion under ground C, that is, risk to mental or physical health.

Senator Noone resumed the Chair.

Is the decision made by one doctor in that case?

Dr. Patricia Lohr

No, two. The only time a decision is made by only one doctor is if there is a risk to the woman's life.

In the case of a combination of serious birth defects, would the decision be made by one doctor or two doctors?

Dr. Patricia Lohr

Two doctors must agree and on the same ground. Both doctors need to be of the same opinion. If one doctor believes the anomaly is severe but the other does not then it may not be possible for the abortion to be performed under ground E.

What recourse does the patient have? There is a purpose to my questions. I am trying to tease out where we are going as a committee, rather than being difficult. Where one doctor takes the view that a combination of conditions will be fatal and a second doctor disagrees with that, what happens? In other words, what happens when there is a difference in medical opinion?

Dr. Patricia Lohr

There is no category of fatal foetal anomaly. The Deputy will find that it is not actually a medical category. There is a consideration of the severity of the anomaly and how that might then affect the child once it is born. If it is the case that one doctor believes that the abortion could lawfully be performed under ground E and another doctor does not then the doctors may consider whether it could be lawful to perform the abortion under another ground. If the pregnancy is within the 24 weeks, that can be considered. For example, the ground of mental or physical well-being applies up to 24 weeks of gestation. If it is the case that a pregnancy is over 24 weeks' gestation, which is the limit for grounds C and D, then the woman would have to seek the opinion of, for example, another doctor.

I thank Dr. Lohr for her attendance and for her very interesting presentation. I would like to tease out with her the issue of criminality of abortion as it applies in this State and, as mentioned by Dr. Lohr in her presentation, to Northern Ireland. Three women in Northern Ireland already have been charged with attaining the abortion pill. Dr. Lohr mentioned that there has been a reduction in the number of women seeking abortions in the UK. She also said that this is probably a consequence of the availability of the abortion pill. The statistics provided by her in that regard tally with those provided by other experts who have appeared before the committee. In Ireland, attainment of the abortion pill is an offence for which a person could go to prison for 14 years. Likewise, it is an offence in Northern Ireland that carries a similar sentence.

What Dr. Lohr said fits with the testimonies to the committee from the Irish Family Planning Association and others, namely, that women mainly seek abortions for socioeconomic reasons. Therefore, they risk losing their liberty in this State because of their socioeconomic circumstances. For some women, particularly refugees or asylum seekers, travelling to the UK can often be out of reach financially. In Dr. Lohr's opinion, is a medical abortion, as opposed to a surgical abortion, the less risky option for a woman in terms of her physical health, mental health and, in the case of an Irish woman, her liberty? In other words if a woman could have a medical abortion in this country, this would be better for her than being obliged to travel to the UK for a surgical abortion because, as outlined by Dr. Lohr, having to travel to the UK often means an abortion takes place later in the pregnancy. I would welcome a response from Dr. Lohr to that point. Also, would she agree that the availability of a medical abortion is preferable and safer? Dr. Lohr mentioned in her presentation that Canada and parts of Australia have opted for decriminalisation. The UK abortion laws are almost as old as I am and without them, women in this country would not have access to abortion.

Are they a bit outdated in that they still criminalise the woman? I did not realise that there was a life sentence attached to illegal abortion in Britain but that is effectively the same here, in the North and in other countries. Will Dr. Lohr give us some insight as to why Canada and Australia opted for decriminalisation? If we get to the point where we have to frame legislation and regulation around abortion, hopefully we will, that would be a good insight for us to have.

Dr. Patricia Lohr

The Deputy's first wide-ranging question was on medical abortion. I answered an earlier question regarding the comparable rates of complications in medical and surgical abortion. It is the case that while complications with either method are extremely low, there is a slightly higher risk of complications after an early medical abortion compared with surgical but the risk profile is different. The sorts of complications that one sees after early medical abortion are relatively minor and can often be resolved with relatively minor interventions, for instance, one might use another dose of medications to remove any extra tissue that has not been passed. The processes for medical and surgical abortion are extremely different, however, and I think it is extremely important that women have access to both because they are so different. Women often prefer medical abortion because it is private, they do not need to have a surgical intervention, have an anaesthetic or go into a clinic in some places. They can pass the pregnancy at home and have their partner with them and that is important to some women. For other women, it is important to them to have their abortion done in a clinical setting, to be performed quickly since with a medical abortion there is a somewhat unpredictable time to the passage of the pregnancy, whereas with a surgical abortion it is a day-case procedure, it is timed and one knows when one will be finished. Often those process-related elements matter in some ways more to women than the absolute rate of complications because the complications are low either way and they are pretty similar. It is important women have access to both.

On medical abortion in Ireland and women availing of abortion medications online, it is entirely unsurprising because it is very expensive to travel. What one sees here is what has been seen in many other countries before abortion was legalised or liberalised, which is that women who can afford to travel for abortions or can afford to pay for them do so and women who cannot do not and go on to have unwanted pregnancies. There are consequences of having unwanted pregnancies too.

On affordability, delivering medical abortion services is a very affordable way of delivering abortion services. It can be entirely nurse-led, the medications are not very expensive and the rate of complications are low. It can be offered from a number of locations, which means that it can be less expensive for the woman as she does not have to travel as far to access services, for example. It is a very good model of care, is a highly effective mode of abortion care and is very accessible.

One issue I had not touched on regarding surgical abortion in my answer to the previous question is that women who have surgical abortions not only need to come over themselves to have the procedure but should have someone come with them and to travel back with them. If they have had a general anaesthetic or some sedation, they should have someone to take care of them afterwards and that adds to the cost. That might see women delaying the procedure further in order to gather the money.

Will Dr. Lohr comment on decriminalisation in Canada and Australia?

Dr. Patricia Lohr

I do not feel that is in my area of expertise so it would not be appropriate for me to comment.

Dr. Lohr has been invited here although her group performs abortions including late-term abortions without time limit, up to birth in some cases. She does not believe and she advocates for a scenario where unborn babies have no right to life. One thing that has not been put on the record is that BPAS received a scathing health and safety reprimand from the British Care Quality Commission after 11 serious incidents in a 15-month period involving women being transferred for emergency medical care in hospitals after undergoing abortions in BPAS clinics. Since Dr. Lohr is coming here to advise us on our laws and on what she regards as best practice, it is necessary that this serious reprimand be flagged. Is that light in which we should view Dr. Lohr's supportive attitude to the idea that abortion should be available outside hospitals and at home, as the World Health Organization pushes for?

She quotes supportively a claim by the Guttmacher Institute, which she says is respected although I believe complaints were made about it coming before the Citizens' Assembly; it does advocate for abortion. Its claim, which is strange to many, is that the rate of abortions in countries with highly restrictive abortion laws is comparable with those with more liberal frameworks. She put the rate in Britain as 16 per 1,000 women. Does that include medical abortions?

Dr. Patricia Lohr

Yes, that is the rate of abortion.

I believe it is one in five. In Ireland, taking Dr. Lohr's figures, it is approximately one in 19, so not quite four times the rate in Britain. Dr. Lohr is not the first witness to come before the committee not to note that. I do not believe she is suggesting that three times as many women from Ireland are going to the Netherlands as to Britain for abortion. Does she accept that we have a much lower abortion rate than Britain and that may be linked to the protective effect of laws that promote the life of two persons, mother and baby?

Dr. Lohr uses terms such as "abortion care" and "when the pregnancy passes", which many people would regard as euphemistic. If one believes there are two humans deserving of care, that situation does not care for the unborn child. Dr. Lohr is an obstetrician. Am I correct in presuming that she has done abortions for BPAS and other organisations?

Dr. Patricia Lohr

That is correct.

Can she give us an idea of how many over the years?

Dr. Patricia Lohr

I want to make a clarification on something that Senator Mullen said in his opening statement. He said that BPAS provides abortion up to birth, which is absolutely not the case. BPAS, as with all non-hospital based providers in the UK under regulation, may only provide abortions to 24 weeks of gestation.

I accept that clarification.

Dr. Patricia Lohr

The second comment related to the Care Quality Commission report about one of our clinics. The Senator characterised it as a reprimand. All health care organisations have opportunities to learn from mistakes. Complications happen and learning must happen afterwards. What was identified in the Care Quality Commission report, as had already been identified internally at BPAS through serious incident investigations and learning that followed, was that we did need to do better at that clinic. However, that will be found in any regulated and inspected health care environment. If anything, it supports the idea that abortion, like any other medical procedure when regulated, has the opportunity to improve and better provide services.

I believe the Senator was trying to say that the fact that we had had this report meant it should not be used as a justification that abortion may be provided safely out of hospital and at home. It is probably better to turn to published studies on the locations where abortions can be safely provided.

We know from a number of publications that, for example, early medical abortion and vacuum aspiration can be safely provided from clinic-based settings. A number of studies have demonstrated that medical abortion can safely occur in the home environment.

There was a comment about an assumption of the abortion rate in Ireland and a connection was drawn between the abortion rate I cited in the UK. The Senator asked whether I thought three times as many women were travelling to the Netherlands. Have I paraphrased that correctly?

What I am really saying is that unless three times as many women are travelling to the Netherlands, our rate is vastly lower than the British rate. I am asking if the witness would acknowledge that disparity in our abortion rates.

Dr. Patricia Lohr

I do not think we know the abortion rate for Ireland. National statistics are not collected, for example, of women who obtain medication over the Internet. I am unaware of whether the Netherlands reports separately on women giving Irish addresses who are treated in that country. As I stated, we can only count in the UK the number of women who give Irish addresses. There may be a number of women coming from Ireland who do not give Irish addresses and who therefore would not be counted in national statistics.

As to the questions about Dr. Lohr's involvement with abortions and an estimate as to how many she has carried out, I also wanted to ask what would be the latest term abortion she carried out.

That will have to be the last question.

I just want to put it on record that there are quite a few more I would like to ask but I realise there is not enough time.

Everybody is in the same boat.

Dr. Patricia Lohr

I am trained to provide surgical abortions to 24 weeks of gestation and I have provided abortions to 24 weeks of gestation for the British Pregnancy Advisory Service, BPAS. When I worked in a hospital setting, I provided abortions at later gestation, usually in the context of obstetrical emergencies. For example, this may have involved women with pre-term premature rupture of membranes and were septic or women with severe pre-eclampsia or eclampsia.

It was not always life-saving, health-related or necessary medical treatment.

Dr. Patricia Lohr

Those would have been provided beyond 24 weeks. These are cases of foetal anomaly and serious maternal indications.

What is the estimate of overall number of abortions carried out?

Dr. Patricia Lohr

I do not think I can give a number. It is hundreds or thousands, maybe. I do not keep track.

I thank the witness.

I thank Dr. Lohr for the presentation. I believe I am correct in saying that most abortions in the UK happen under the broad mental health grounds, with sign-off from two doctors. Are women ever denied an abortion on these grounds? What would the reasons be for a denial? Does the phrasing of the grounds and the verification process ever act as a barrier?

Dr. Patricia Lohr

We do not count the numbers of women who are denied so it is difficult for me to answer that question accurately. Within our service, there have been circumstances like we discussed earlier where the doctors have not always agreed on the grounds and so there has had to be more discussion about whether the woman would be eligible and under which grounds. There have been circumstances where doctors have felt a woman needs to go away and think more about the abortion or there have been cases where women have presented requesting abortions on the grounds of foetal sex. In and of itself, that does not meet the grounds for the Act and further discussion would have to happen to ascertain whether the impact of continuing the pregnancy would mean the women would qualify for an abortion under another one of the grounds.

I feel strongly about ensuring this country allows access for women on social and economic grounds. Is that catered for properly? There is a wide range of social and economic impacts but is that captured under ground C?

Dr. Patricia Lohr

Ground C can be interpreted very broadly but the ground that touches on what the Senator is discussing is ground D. This is where an abortion might be authorised on the potential impact of continuing the pregnancy on the woman's existing children. We often see it with regard to considerations of socio-economic status. For example, a woman would have children and cannot afford to have another child. Socio-economic considerations can come into play under ground C and within the Act the doctor is given the ability to consider the woman's current position and her foreseeable future. Such wording is used within the Act.

The witness has made a strong case for decentralisation of abortion care, with mention of potential administration of abortion by GPs, nurses and midwives. How important is this in the context of reducing geographical barriers to abortion access and also in the context of the well-developed trend of anti-abortion protests in the UK outside approved clinics?

Dr. Patricia Lohr

There is potential ability to have nurse-led services in particular for medical abortions. In the UK, a doctor must always sign the prescription for the medical abortion drugs, for example, and they must always authorise the abortion. Those medications can then be delivered by a nurse and peri-abortion management can be done by a nurse in our setting. It is a more affordable model of care than utilising doctors to deliver abortion care and this has allowed us to set up a number of small units closer to women's homes around the country. That has been a strong contributory factor in the increase of early medical abortion and the knock-on effect of having the gestational age that women are able to obtain abortions come down.

My other question was on decentralisation. If a woman can access this care with her local GP or in the primary health service, it would stem the level of protest.

Dr. Patricia Lohr

I cannot speak to that in Britain because we do not have that. In the United States, when I provided abortion care, I did it during my office hours doing gynaecology. I might have seen one woman for an abortion and the next might have had abnormal uterine bleeding, for example. I might have seen the next woman because of a vaginal discharge. All of those women sat in the waiting room, anonymous to one another about why they were there. They were less likely to be a target. If one comes to an abortion clinic, one is potentially a target.

There are six people who wish to contribute and we only have approximately 20 minutes remaining. I ask people not to be repetitive and keep the contribution to five minutes, if possible.

I will have to be good. I thank Dr. Lohr for coming in. It is interesting that Senator Mullen made the point about Dr. Lohr's services being the subject of a critical review while in the Dáil Chamber they are discussing Portlaoise hospital. It is the subject of scathing reports arising from the death of babies. The solution was not to shut the maternity service but to improve it. Dr. Lohr's comments on the need for every medical procedure to be constantly improved were well made. We have an unusual position as Irish people have a constitutional right to have an abortion but we do not have the right to have it in Ireland. On behalf of the tens of thousands of Irish women who have availed of Dr. Lohr's services, I sincerely thank her for that.

Will the witness speak to the point about the irony that our abortion regime, if one likes, arises from the 1967 Act, which is the only avenue Irish women in the main have been given if they have the money to travel?

In the context of the 50th anniversary of that Act and the increasing dialogue on the need to modernise the British service, what are the best lessons for us, given that we will be starting, in essence, from scratch? The witness has addressed medical abortion, but I was struck by the point that in a scenario where there is funded legal abortion services, hundreds of women in England or Wales are accessing the service from Women On Web. Is that an illegal activity or is it a grey area? How can we learn from that?

I am confused. We have spoken before about the call by the head of the Royal College of Obstetricians and Gynaecologists asking for nurses and midwives to be allowed to administer the abortion pill on the basis of one doctor. My understanding was that that does not exist now and that it has to be two doctors, and that nurses and midwives cannot do it, or that they can when there are two doctors. Perhaps the witness could clarify that; it is potentially an important way forward.

The impact of decriminalisation and what it would mean is another area that is linked to this. It is a discussion that is happening in Britain at the moment and has been discussed in every session we have had here. What will it mean and how can we learn about it?

Dr. Patricia Lohr: The Deputy is correct to observe that Irish women currently have their abortions within the confines of the 1967 Act. There are a number of problems for women with the way the Act is written. A positive from the Act is that those definitions of the grounds for abortion are widely interpreted, and that has meant that most women who need to have an abortion are able to access that, but it is the case that there are some women who cannot. For example, the door closes when the gestation passes 24 weeks unless there is a serious foetal anomaly or a threat to life.

The question of when a woman's life becomes endangered is an important one. Where women present stating that they are suicidal, what are the mechanisms that one needs to go to in order to ensure that is the case? That puts up serious barriers and creates a situation where women and doctors are struggling to ensure that they are working within the law, while what the woman needs is to end the pregnancy which is so burdening her.

The Deputy mentioned women accessing or trying to access Women on Web because they feel that the current framework under which abortion is delivered in the UK is a barrier. It consists of having to go into a clinic and using the medications in the clinic, having to have more than one appointment and having to have a doctor sign off. In some cases, although it is not a funding requirement some of the funding bodies require that a woman goes to her GP and gets a referral into abortion care. For a woman who does not want her GP to know that she is having an abortion that is a barrier for her. Women on Web do not provide medications to women living in Britain. It would be an illegal activity if those women did obtain medications over the Internet. Women on Web will provide women with advice and guidance on how they may obtain lawful abortion care. However, we know from the requests received by Women on Web it is the case that the way that medical abortion is delivered and the restrictions on how women can obtain those medications is a barrier to them accessing services which could be provided safely and better. If we were able to provide women with truly telemedical medical abortion services, such as those that exist in some parts of the United States, they could freely and openly have a consultation, perhaps using a web chat-type module. They would have access to follow-up ultrasound scans, anti-D immunoglobulin etc., that women who obtain these medications over the Internet are not always able to access.

Are my answers too lengthy? I am trying to pick up on each of the points.

No, the problem is that time is too tight if the witness is to get to the airport on time. The flight time is at peak traffic time, it is a bad day weather-wise, and I am conscious of that. I should not have to be thinking about these things as Chair.

The witness is very welcome, and her answers have been extremely informative. As Deputy Daly has pointed out, there are of course thousands of women in this State who owe a debt of gratitude for the provision of services that we simply cannot access in this State.

The witness is saying, on the issue of the provision of abortion pills, that the absolute best scenario is that treatment is delivered as close to home as possible for the woman herself. Speaking practically, the necessary pills could be provided by a nurse; there would not need to be any level of specialist skills. A GP could do it. One need not work in the area of obstetrics-gynaecology. Is that the case?

On the issue of conscientious objection, the witness referred to work that she had carried out in the United States where she provided a full range of health care. The master of one of our maternity hospitals was very clear about what a full range of health care is for women. In the facility where the witness provided that health care was there accommodation made for a person who might have a conscientious objection? The issue is often raised by people. I am sure that accommodation can be made, but I would like the benefit of the witness's experience.

Dr. Patricia Lohr

To be clear, in the UK at the moment a nurse may not prescribe abortifacient medications. She or he may give those medications under the direction of a doctor. A doctor must prescribe the medications and then the nurse or midwife may administer those medications and manage the abortion through to aftercare. It is absolutely the case that nurses, midwives and GPs can do this safely. What they need to do is understand the medications in the same way that they would understand any other medication they would provide, including the indications, the contraindications, the side effects, the potential complications and how to manage them. It may not even be the case that a GP himself or herself would have to manage all of the complications. They could work, for example, with a hospital setting. If a woman needed a surgical evacuation for incomplete medical abortion they could work with a colleague to provide that if it was not provided in their office, although as I have said it is safe to provide early vacuum aspirations from an office-based setting.

It is normal to provide for conscientious objection no matter where one is working in obstetrics and gynaecology. In fact, it is protected within the abortion Act for the treatment itself. Individuals may enact their conscientious objection to participate in abortion treatment, but that does not absolve them from participating, for example, in the management of complications of abortions. That has been the case in other places where I have worked, where I was providing the full range of women's health care.

I appreciate the Deputy's brevity.

I welcome the witness and thank her for the clarity of her responses. I join with recent speakers in acknowledging the service that her agency provides to a great number of Irish citizens, women and their partners, service which for a range of reasons are not available here.

I want to clarify an area that was covered by Deputy Bríd Smith.

On the matter of Irish women having surgical abortions, 71% compared to 28% for female residents in England and Wales, am I correct in assuming the 72% of English and Welsh concerned opt for the medical option for reasons of perceived safety or just for convenience? As a corollary to that, if there is a safety factor, would it be of concern to Dr. Lohr's agency that such a high percentage of Irish women are not able to avail of the medical procedure? To take it a little further, would Dr. Lohr - it is difficult logistically for many as it is a stressful time - advise women perhaps to stay a little longer? Whereas Dr. Lohr referred to the fact they liked to fly in and out of the UK on the one day, it is a big decision for people to take. I wonder if Dr. Lohr would encourage them to stay a little longer and, therefore, be able to avail of both options.

Dr. Patricia Lohr

I will take the latter one first. We do advise that women stay because the most likely time to experience a complication is in the first several hours or 24 hours after an abortion. We talk to women about how it is preferable to stay but the reality is that most women cannot afford to stay, and it may not only be for financial reasons. They cannot afford to be away for reasons of secrecy and stigma, to be unaccounted for.

The Senator also asked why so many women in Britain choose the medical option. The reasons are very varied. Some women perceive it as being safer because it is a non-interventional method of abortion. Some women choose it because it is readily available. It is offered in a number of locations. When women have an unwanted pregnancy, they would like to be not pregnant as quickly as they can and if they can avail of a medical abortion more quickly than a surgical abortion, they may opt for that in order to achieve the abortion more quickly.

However, as I said previously, there are aspects of the process and the characteristic of the method that also matter. It is non-surgical so they do not have to have an anaesthetic. They can pass the pregnancy at home or be with their partner. They just prefer that option to having to come into a clinic and have an interventional procedure which may be associated with an anaesthetic that they also do not want to be exposed to.

I thank Dr. Lohr.

I thank Dr. Lohr for her presentation earlier. I am seeking clarification more than anything else because many of the questions have been asked.

Perhaps Dr. Lohr could explain this to me. It is possibly a lack of understanding on my behalf but when a person presents for an abortion at one of the British Pregnancy Advisory Service clinics - I am just trying to tease out the idea here - is there the opportunity for scans or anything else like that, particularly for late pregnancy presentations? The reason I ask that question is that we had various speakers in over the past number of weeks who discussed the viability of the child in the womb. I am just wondering if the service looks at that. Dr. Lohr stated earlier, in response to one of the members who asked about fatal foetal abnormalities, that the service does not really record it. Does the service record it? My questions are about viability and scanning, and the crisis pregnancy management, particularly for a late presentation.

There is obviously some electronic device near the Deputy. I ask members to be mindful of that.

Dr. Patricia Lohr

Every woman who has an abortion at the British Pregnancy Advisory Service, BPAS, has an ultrasound to ensure the pregnancy is intrauterine and to look for viability. When I say, "viability", I mean in early pregnancy because we provide miscarriage management and if we identify a miscarriage or a miscarriage in process, we would have a different conversation with the woman than if we were counselling her about an abortion. We also scan to determine the gestational age.

BPAS does not scan for anomalies. The women we treat who have been diagnosed with a foetal anomaly will normally have been referred in to us from a foetal medicine centre and it is not in our ability to perform those sorts of ultrasounds. I hope that answers the Deputy's question.

I was merely curious.

Dr. Patricia Lohr

Deputy Rabbitt's other question was about crisis pregnancy.

Yes, particularly for late presentations. If a person has presented at 20, 23 or 24 weeks, and this goes back to the viability, does BPAS give her the opportunity of the conversation beforehand or do women come with a definite mind that they are there to have the procedure performed?

Dr. Patricia Lohr

Every woman has the opportunity to talk about her thinking about the pregnancy. Every woman is asked, "Have you made a decision about what you want to do with this pregnancy?" Every woman is given the opportunity to speak to a counsellor if she needs to have a more full pregnancy options discussions, and if there is any degree of ambivalence if she is unsure.

I thank Dr. Lohr for the presentation. I have only two quick questions. The first is obvious, or perhaps not. Does Dr. Lohr's service experience high numbers of women from countries other than Ireland coming over to avail of its services?

Dr. Patricia Lohr

We see far fewer women from countries other than Ireland. Most of the women we see who are travelling from abroad are from the Republic of Ireland, but we do see other women. Senator Gavan has not asked this question, but they come for similar reasons - abortion is restricted or perhaps the gestational age is restricted in the country from which they come.

Would Dr. Lohr give examples of the sort of other countries they might come from?

Dr. Patricia Lohr

We see women from Italy and some women from Spain. We also see women - usually, they are expats - who are living in the Middle East, for example, where they may not be able to access abortion care.

Can Dr. Lohr give us a flavour of how access to abortion and the BPAS are viewed in Britain from a moral or a principle's based point of view?

Dr. Patricia Lohr

I am a bit biased because I am extremely proud to work for BPAS. We are viewed as a safe pair of hands for abortion care. We are viewed as an organisation which champions the ability of women to make decisions about when and whether to parent or carry a pregnancy. We are viewed as a fiscally responsibly organisation, as a charity. We are a not-for-profit organisation and because we provide good abortion services, we are seen as being experts in providing abortion care, particularly in the second trimester and for early medical abortion.

I thank Dr. Lohr.

I thank Dr. Lohr for her presentation here today. I am conscious of the time. The traffic could be bad and we really need her to get to the airport. I thank her so much for her attendance here and for the information she provided. We are grateful to her.

Dr. Patricia Lohr

I thank the Chairman.

The meeting will suspend for five minutes.

Sitting suspended at 4.18 p.m. and resumed at 4.31 p.m.