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Joint Committee on Health díospóireacht -
Wednesday, 18 Oct 2023

Report of the Review of the Operation of the Health (Regulation of Termination of Pregnancy) Act 2018: Discussion (Resumed)

The main purpose of the meeting today is for the joint committee to further consider the review of the operation of the Health (Regulation of Termination of Pregnancy) Act 2018, the report which was conducted for the Minister for Health, Deputy Donnelly, and was referred to the committee by the Minister for consideration. The committee has already met with Ms Marie O'Shea BL, the chair of the review in May of this year when we discussed the matter in detail. Arising from that, members were individually invited to identify issues of concern to them which they felt were not covered at the original meeting, and these have been circulated again to members and to Ms Marie O'Shea. The purpose of today's meeting is primarily to address some of these outstanding issues.

To assist the committee further in its consideration of the review, I am pleased to welcome again Ms Marie O'Shea who is accompanied by Dr. Catherine Conlon, assistant professor in Trinity College Dublin, and Dr. Deirdre Duffy, senior lecturer at Lancaster University. I thank Dr. Duffy for travelling over, at considerable expense to herself, to attend the meeting this morning. On behalf of the committee, we appreciate that.

Witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable, or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed by me to discontinue their remarks. It is imperative they comply with any such direction.

Members are also reminded of the long-standing parliamentary practice 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 also remind members of the constitutional requirement that they must be physically present within the confines of the Leinster House complex to participate in public meetings. I will not permit members to participate where they are not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting. In this regard, I ask any members taking part via MS Teams that, prior to making their contribution to the meeting, they confirm they are on the grounds of the Leinster House complex. As this is Ms O'Shea's second engagement with the committee, she will not make an opening statement but she may wish to make some introductory remarks.

Ms Marie O'Shea

I first thank those members of the committee who sent in written questions earlier this year. I appreciate the consideration they have given to the review. Unfortunately, because of my own work commitments, I could not come back to the committee or respond to those questions. My preference is to respond face to face because I believe if I did so on paper, it might not answer all of the issues which the members wanted to have clarified. I am delighted to have two key researchers with me here today, Dr. Deirdre Duffy and Dr. Catherine Conlon, who helped considerably in the review.

At the outset, I might reiterate that the terms of reference for me for this review were to assess the extent to which the regulations in the 2018 Act had been achieved and where they were not achieved to make recommendations. While I drew on the WHO abortion care guidance and other international mandates we have as regards a human rights approach to termination of pregnancy, it was not part of review to compare the Act and assess how it measured against those instruments, but I am happy to talk about them in the context of the review.

I thought I should clarify that at the outset.

I thank Ms O'Shea.

I thank the witnesses for taking time out of their busy schedules to be with us. That is very much appreciated. I thank Ms O'Shea for her work and all the people who assisted her in preparing her report.

I acknowledge that the criminalisation issue did not come under the terms of the review in which they were involved. I am asking this, as someone who has a legal background, of someone else who works in the legal area. Does Ms O'Shea believe it is causing problems within the health service as regards providing services and is there a need to change that? It is about putting a mechanism in place to ensure there is a balance. Can we do that by removing that criminalisation element?

Ms Marie O'Shea

The evidence from Dr. Duffy's work and from the work I conducted with service providers is that the criminal sanction of providers weighs heavily on their minds. In the context of the Act, it is interconnected with the operation of sections 9 and 10, which provide for termination care where “there is a risk to the life, or of serious harm to the health, of the pregnant woman”, and to the operation of section 11, which relates to trying to determine whether the foetus will demise before birth or within 28 days after birth. Because medical science is not exact, it is an educated guess. There is no definitive list of conditions that will say something will lead to death within 28 days, so a lot of it is educated guesswork.

In the case of section 9, which some of the Deputy's colleagues raised in written questions, there is a degree of confusion about its operation, which arises from its wording. When we put that together with cases that went wrong and the media scrutiny that surrounded those cases, I am told universally by medical practitioners that the impact of a criminal sanction hanging over them has a chilling effect, and that was the term used by almost all of them. It was one of the main provisions they wanted to be removed from the Act.

Dr. Deirdre Duffy

To reinforce what Ms O'Shea said about the position of service providers, I can quote directly from the report and from our data. A consultant neonatologist asked for the “criminality aspect of the Act [to be] removed or dealt with really significantly to allow people to practice in a professional way and would make people feel more protected”. The position of service providers, therefore, including consultants who are specialists relating to this Act and who are central to the delivery of service, is that the continued criminalisation is impacting on their practice.

If we were to remove that, could we still put in place a safe set of rules to make sure people would not exceed their jurisdiction in taking decisions? That is one issue that will be raised. If, for instance, a doctor does not in some way deliver a medical service, he or she can be reported to the Medical Council. Are the witnesses satisfied that, if we remove that criminal element, there will be enough safeguards to ensure the best possible service will be delivered to the patient while, at the same time, having adequate restrictions on doctors to comply with the law?

Ms Marie O'Shea

Yes, definitely. The Act will still prevail on people a statutory duty to keep within its parameters, which will be actionable in the civil courts and possibly actionable, depending on whether there is a survivor after birth, under the Non-Fatal Offences Against the Person Act, so there is law that would protect the public.

I might move on to the issue of fatal foetal abnormality and the definition of that, which Ms O'Shea touched on when she was replying to me earlier. I have come across a case in one large hospital, for instance, where the wishes of the patient were not dealt with. The person was going to the UK and was persuaded to check in with another medical facility. At that medical facility, their case were reviewed by two senior consultants, who took the decision, and in fact the decision was the correct one, that there was a fatal foetal abnormality. When that arises, there is no right of appeal and so on. Is there an adequate safeguard to deal with that issue where people find that the medical facility is not taking the best decision from their point of view and for their long-term healthcare?

Ms Marie O'Shea

That illustrates the subjectivity of the decision-making. We would expect that the larger hospitals might have a larger volume of cases and that, therefore, there would be experiential learning, perhaps more than would be the case in smaller foetal medicine units, but I am told by people in the larger hospitals that it is an issue for them as well. There are also separate issues relating to the supports that are needed to assist in making the diagnosis, one of which is access to consultants in foetal genetic medicine, although I am not sure whether that is the correct term-----

The smaller maternity units would not have access to that without referring the matter.

Ms Marie O'Shea

Certainly at the moment they do not. There is no foetal medicine specialist employed by the State at the moment. When I was writing this report, the National Maternity Hospital was employing one out of its own finances, namely, Dr. Sam Doyle, and her appointment was regarded as a game changer. Even in that context and even where there is a perfect diagnostic system, I am led to believe it is still virtually impossible to say how long, if the baby survives the birth, he or she will live.

Turning to the three-day review, has sufficient research been carried out? The witnesses have produced a very comprehensive report, but I have received correspondence from people who believe insufficient research was conducted on that aspect in completing the report. Would it be helpful if additional research were carried out on that, especially relating to the numbers who did not come back for a second appointment? Should more research be done before we proceed to making any changes?

Dr. Catherine Conlon

It was specifically our study that looked at service user experiences and women's pathways through the model of care for abortion in the health service. We set out to make contact with anybody who had entered into the abortion care pathway or crisis pregnancy supports care pathway and to interview them for the study. In the event, nobody who had had a first appointment and did not proceed with a second appointment opted in to our research.

As to why someone might undergo only a first consultation, there are many reasons and doctors working in this area have commented on that.

There are many reasons somebody would not return for a second visit. For example, the pregnancy may have miscarried. The fact that somebody has a consultation with a GP about a pregnancy, even under the abortion model of care, does not necessarily mean - and our data support this - that they are considering abortion. They are looking at their care options under the health service.

But my question, really, is-----

Dr. Catherine Conlon

Sorry. The assumption or the conjecture is being made that for people who attend for a first appointment and do not attend for a second, it is the value of the three-day wait that means they do not come back. First of all, the only systematic evidence we have as regards people who do not return is from the Irish Family Planning Association because the nature of our data collection is totally deficient, so the data collection systems as regards the service are one thing that certainly could be looked at in the review.

My question, basically, is whether Dr. Conlon believes that more research needs to be done on this before a final decision is taken on reviewing this aspect of the legislation.

Dr. Catherine Conlon

No, I do not believe that, but what I would recommend is that our data collection systems as regards the service are much more systematic in order that we can understand people's pathways through the care service for quality reasons. The systematic research that has been undertaken from the data set that is able to look at people's patterns of return or otherwise by the IFPA does not suggest a high rate of people who are opting out because of the three-day wait.

Ms Marie O'Shea

May I add to that point briefly?

Ms Marie O'Shea

During the research, I heard from the service providers I spoke to that we needed better monitoring and evaluation systems to develop better public policy around the delivery of termination-of-pregnancy services. There is certainly no reason, if it were possible, not to collect those data as well. It would be interesting to collect them from a public policy point of view.

The other issue is that, in doing this research, although we had a limited period, I think a retrospective study of people who did not attend for the second review would be very difficult to do. Many people do not attend their own GP for the service but go to a different GP because in many areas there are very few GPs who provide it. One would be relying on GPs for the actual recruitment of these people.

Second, I have sat on two ethics committees for a long time and I do not think an ethics committee would necessarily approve that type of retrospective research looking at that issue because of the potential harm it could do to somebody to get an invitation to engage in research as to why they considered having an abortion where the child is sitting there in front of them. This is just my personal view from my experience, but I think that would be difficult.

Certainly, monitoring and evaluation of the whole service should be considered. I do not think it is necessary, as to whether or not this committee considers legislative change, to amend that provision. We are not suggesting that the model of care changes. I am a legal person and I talk about rights. There is a right to a second visit that is free of charge as well, and I do not think this committee can disregard what we heard about the barriers this is causing to people who potentially time out because of the three-day wait or because of the three-day wait combined with the lack of 365-day services in the hospital setting, which is where a person has to go from ten weeks. Also, that cohort of people who are accessing inclusion medicine services have chaotic lifestyles, and coming back for a second appoint, to them, if they have an addiction or are homeless, can be quite challenging. We have quotations in that regard in Dr. Duffy's report. It was also something that was said to me quite a lot by medical practitioners working in the community. They talked about the difficulty with providing care to those persons. They are discriminated against by the three-day wait.

Again, I apologise for cutting the witnesses off but I am trying to do this within ten minutes.

Ms Marie O'Shea

I apologise.

It is grand. We will have a comfort break at about 11.30 a.m., in ten minutes. Deputy Cullinane is next.

I welcome back Ms O'Shea and thank her for taking the time to be here. We had some lengthy discussions the last time she was here and it was very helpful to unpack some of the recommendations. I will make just one broad point about the current legal architecture which underpins abortion services. Ms O'Shea will be aware that many people have a concern about the criminal underpinning of that architecture. I think she made reference to this in the context of World Health Organization trends and so on. As to what she recommended, there are some who would argue that her report has not gone far enough in this space. Was that because of the limitations of the terms of reference or were there other reasons? What is her general view of that criminal underpinning of the current architecture of abortion services?

Ms Marie O'Shea

The terms of reference were informed by three strands, namely, the public consultation, the service providers and the service users. The matter only arose in the context of the research that was carried out in terms of the effect it had on the service providers. That is all I am really qualified to comment on, and that is why that aspect is dealt with in the report. I acknowledge that the WHO guidance and the international human rights bodies' approaches to termination of pregnancy are that it should be decriminalised in full. There is an evidence base for that, but I cannot put it any further than that in terms of my recommendations. I have to go on the data I collected.

Dr. Catherine Conlon

As regards the effect of the criminal sanctions in the legislation from the service user perspective, the people we spoke to who were seeking care certainly could discern the chilling effect of the criminalisation, particularly as regards termination in cases of fatal foetal anomaly. As regards a legislative architecture underpinning abortion in our healthcare services, where it is having that impact of interfering with the relationship between the doctor and the person seeking care under very stressful circumstances, that, from our perspective, in terms of the service user, certainly needs to be looked at.

Dr. Deirdre Duffy

Similarly, from the service provider study, which I can speak to directly, having been the one who has conducted the provider research, very clearly the location with regard to the criminal penalty is impacting conversations and decision-making from providers who are specialists. They are conducting and undertaking conversations with patients with an understanding that there may be a criminal penalty facing them, and that is impacting care directly. That was an area of consensus across participants in our study.

That is helpful. The three-day wait period is one of the areas of Ms O'Shea's report and one of the recommendations that got the most coverage. It seems to be more black-and-white for people. There are some who just oppose removing it. I support removing it and never saw a rationale for it in the first place. Notwithstanding my opinion on it, however, Ms O'Shea's clear recommendation is that it should be removed and that the other option is there for reflection if a woman wants it. As regards the impact of that, which is what is in contention at the moment, it would be helpful if Ms O'Shea were to outline today from her perspective what she feels the impact of removing the mandatory three-day wait period would have.

Ms Marie O'Shea

As regards the psychological effect on the women who attend for these services, there are peer-reviewed papers and I think it was the UnPAC study that found that it had a detrimental effect in that they could not be trusted to make a decision. There is also the point of view that GPs are under a lot of pressure. If the person is sure about their decision on the first occasion, why do they need to come back for a second visit? The Assisted Decision-Making (Capacity) Act, which has now been commenced, refers to people on the presumption that they have capacity to make a decision. I was at the START conference, where I talked to a great many GPs who were all of a view that this is a holistic type of care and is not care that is aimed at giving somebody abortifacient medication. The first consultation lasts 45 minutes. It is a matter of discussing with patients and making sure they have considered their decision before they come back on the next occasion.

If it were removed, the model of care is not going to change. As I said in the report, people would be told that they have a statutory right to reflect and even that, on reflection, may be something that is quite patronising. Perhaps it does not have to be read out to them like that. Perhaps it is a statutory obligation on healthcare professionals to outline what the model of service is, and that they do not have to proceed on the first occasion whether that is because they have any doubts or the time taking the abortifacient medication, and managing the termination of pregnancy, would not be the most convenient time for them, and they have until such and such a date to do that. I think that would protect people.

From all of the research and all of the very extensive work done by Ms O'Shea and the people who have worked with her, she is very clear that there would be very positive impacts-----

Ms Marie O'Shea

I believe so, yes.

-----and necessary impacts from the removal of the three-day wait period.

Ms Marie O'Shea

Yes, that is what I am informed.

It is very clear and emphatic in the report that this needs to be removed.

Dr. Catherine Conlon

Yes.

Ms Marie O'Shea

It is prejudicial to the rights of people as well.

Dr. Catherine Conlon

To bolster that, and from our study again, we talked to people who had accessed this care. They said that they went to their GP. It took some time to actually get to the GP, and time is really important in this service. There was a delay in getting to the GP. When people got to the GP, it was only then really clarified that they had this legally enforced three-day wait. There is no clinical reason for the wait. It brought no clinical quality to the model of care or care. For the people who attended, they attended a service and GP clear as to their competency in making a decision and then they were told there was a legally enforced three-day wait. People said they may have opted, and I think this is the basis for Ms O'Shea saying the model of care should retain a second opted-into appointment. The model of care in Ireland means one has to self-manage the abortion process at home, if you are under nine weeks. In order to do that, a second appointment for sure is beneficial but a mandated three-day wait was oppositional to women's well-being.

Dr. Deirdre Duffy

I think this was the point of view from service providers, again quite cohesively, that the mandatory aspect was problematic. It is also worth bearing in mind that it is problematic for the reasons of timing out, and the reasons that this is not a 365-day service, so it creates operational problems. I refer to specific categories of vulnerable populations for whom making multiple journeys is a significant barrier to care. For service providers, this mandatory component is introducing artificially barriers to care that are having uneven effects and impede access to the service.

The last time we were here I asked about the sequential implementation of the recommendations and what was felt was possible here because there are some recommendations that I would argue need to be teased out. I ask the witnesses to echo that again in terms of their recommendations to legislators, where would they start, what could be done immediately and how legislation could be changed.

There was some criticism, which I think was unfair, levelled at the witnesses and others in terms of the research and a contention that there was not enough engagement with service users. I want to give the witnesses an opportunity to answer that criticism. I ask them to set out again how they see their recommendations being implemented and the advice they would give to legislators.

Ms Marie O'Shea

On the sequence, the criminal sanction, as it applies to medical practitioners, would encourage more medical practitioners to come on board. It would take some of the tension, as described and originates from criminal sanction, out of the multidisciplinary team meetings. I think that would definitely help in terms of recruitment and service provision.

The three-day wait could be legislated for as it would certainly help women. It does not appear to serve any functional purpose, particularly if safeguards are there to keep the model of care in place and for people to know about that model of care.

In terms of engaging with the service users, certainly in light of the UnPAC report and the public consultation, there were just under 7,000 submissions to the public consultation. Some of those were in favour of changing and making the legislation more open while some were in favour of restricting it. A lot of the submissions came from organisations that represented service users and service users themselves, so certainly their views were taken into account. I will ask my colleague to talk about the terms of reference for the report and service users.

Dr. Catherine Conlon

I was the principal investigator, PI, of the services users strand. The Department of Health designated the UnPAC study, the service users strand of the legislative review, after that research was well under way. It was not commissioned as part of the review, as Dr. Duffy was. The HSE had begun our research in December 2019. In April 2021, the Department of Health designated it the service users strand of the research. One of the reasons was because of the rigour and the extensive nature of that research. We began the research in December 2019, under terms of reference by the HSE. We undertook research recruiting people for the study in 35 general practitioner sites, two hospital sites, two women's health clinic sites, and through the organisation of Termination for Medical Reasons group and BPAS UK. We engaged with more than 60 GPs. We invited all GPs on the list, providing abortion, through the contracts office, to take part in the study. We did extensive work on trying to access people. It took time. We went back to the HSE and it extended our timeframe. We talk about recruiting people for the study. It is a very lengthy and sensitive process to engage people in research like this.

We ultimately engaged 46 people in this study. When we look at international peer review, it is a much more extensive research with abortion service users. We did qualitative interviews that lasted one hour and upwards. We have more than 60 hours of data with people who have accessed care under section 12. In addition, we have 12 interviews of more than 20 hours of data with people who have accessed care under section 11.

We would say we have made extensive efforts to consult with service users on this research. There is no more rigorous methodology. It has been peer reviewed extensively. The rigour of our methodology has been held up by academic peer review as well as peer review by the HSE.

Again, I am conscious that members are asking questions. There is only a minute in which to respond. That is unfair to witnesses so I ask members to work with me. A lot of people want to comment. I want to be fair to everyone, so I ask members to give me some leeway. Our next questioner is Senator Clifford-Lee.

I appreciate that some of my questions have already been covered. I thank Dr. Conlon for clarifying the rigorous extent of the peer review and examination of the research. I know all three witnesses are very experienced in this area and I appreciate the clarification.

On the three-day wait, I thank the witnesses for outlining what they believe would be a positive impact on women if the waiting period was removed. I also note the statutory right of reflection. Initially, when I saw this report, I was a little taken aback that it contained this aspect. I appreciate that the position that it is perhaps patronising has been put forward but I understand a balance had to be struck and agree that it is patronising. I am not aware of any other care in the medical system where people are told to take time to reflect when they have made their mind up about something. Indeed, on the approach taken by medical practitioners, they always take informed consent before undertaking any medical procedure. I think that we need to keep all that in mind.

Over the past couple of months I was struck by the lack of understanding among the Legislature about conception and the detection of pregnancy. I ask the witnesses to outline, for the benefit of this committee, at what stage a pregnancy is detected.

Many people were surprised to hear that it is often seven, eight or even nine weeks before a pregnancy can actually be detected and even that is only if a woman has a regular period cycle and is expecting a pregnancy. I ask the witness to elaborate on that for the benefit of the committee.

Ms Marie O'Shea

The 12-week period starts from the first day of the last menstrual period. That is how doctors and other medical professionals would date a pregnancy. It is difficult for people who have irregular menstrual cycles, who are using contraception that failed, who do not have the typical signs of pregnancy or do not recognise those signs and for those who have chaotic lifestyles, as compared with people who have regular menstrual cycles and who would be more au fait with whether or not they are pregnant. The clock starts ticking before conception. It would be-----

Before sexual intercourse takes place, the clock starts ticking.

Ms Marie O'Shea

Yes, before the person is considered pregnant.

That is possibly two, three or four weeks prior to conception.

Ms Marie O'Shea

It starts on the first day of the last menstrual period.

The first day of the last period.

Dr. Catherine Conlon

Again, based on our data from the service user perspective, the women we spoke to had all been subject to that model of dating of pregnancy. My own PhD study looked at women who had experienced undetected or concealed pregnancies so it is something I would have extensive experience of researching. Women were talking about the missed period. If one has a regular cycle, that is the first indication of a pregnancy. As Senator Clifford-Lee has said, even if a woman has the pregnancy detected within a couple of days of a missed period, the dating of that pregnancy will already be four weeks.

If a woman misses her period and takes a pregnancy test two days later-----

Dr. Catherine Conlon

She is already at four weeks.

She could be four weeks or six weeks pregnant at that stage.

Dr. Catherine Conlon

Exactly, but a lot of people will wait to be symptomatic. Getting a GP appointment in Ireland can take quite some time. Obviously there are self-testing kits but people often wait and have the pregnancy confirmed with their GP.

I am sorry to interrupt but the self-testing kits are not foolproof either.

Dr. Catherine Conlon

Exactly. It depends on hormone levels. Some people might have very low hormone levels and the pregnancy is not detected until the hormone levels get more established and the pregnancy is more advanced. Regardless of the point in a woman's actual bodily cycle when a conception happened, the date of a woman's last menstrual period as she reports it to the doctor is the date from which she is considered to be pregnant. Obviously, there is some movement on it but that is the formal legislative criterion. People were saying to us that they thought they were at seven or eight weeks but when they went to their doctor, they were detected to have been more advanced in pregnancy. Our cut-off point of ten weeks for community care or nine weeks plus six for community-based care is reached very quickly. To then have to go into the hospital system, which as Dr. Duffy's research found has very constrained resources, means that time is moving very quickly, often for logistical reasons as well as because of that way of dating pregnancy.

That was really helpful. Many people who would not be familiar with being pregnant might find it hard to wrap their heads around the concept that people do not have a full 12 weeks to decide but actually only have a very limited time. When one factors in a three-day wait on top of that, it can be extremely problematic, even with the best will in the world. As Dr. Conlon outlined, for people who have certain medical conditions, who have irregular periods or who have a lot going on in their lives, it might be extremely difficult.

Dr. Deirdre Duffy

It is worth pointing out that service providers reinforce this wholeheartedly, for all of the reasons the Senator has mentioned but also because of the operational and logistical delays that happen as an ordinary part of referral between different parts of the health system. That system does not operate on a 365-day basis and there will be a natural operational lag between appointments, for example, or a gestational scan, if required. If the gestation is unclear and a provider in community care requests a gestational scan, then the person needs to travel to a hospital and so on. All of these little impediments can lead to delays and including a mandatory element to that is compounding an existing problem. Someone can very easily time out of care.

Ms Marie O'Shea

I should say that in our study there was a person who had been the subject of a sexual assault and was pregnant as a result of that. The trauma of that inevitably meant that time was an issue. We need to carefully look at the impact of our model of care, our particular way of dating the pregnancy, and our very tight time constraints on the care pathway through the health service.

Dr. Catherine Conlon

In response to Deputy Cullinane's earlier question, I would put a hierarchy on amendments to the Act and focus first on section 12 and loosening that.

My time is very limited but I want to talk about barriers to care, a number of which are outlined in the report. Are our guests aware of certain groups of people who experience particular barriers to care? I am thinking, for example, of people in direct provision, people who are based in rural areas-----

Dr. Catherine Conlon

In terms of the early-----

-----or people from particular ethnic minorities. If so, would they make any particular suggestions in relation to vulnerable groups?

Ms Marie O'Shea

Not having a PPS number is the first barrier to care because the service is only free of charge to those who have one. That said, I know that the IFPA has absorbed the cost of providing the service to such people in certain circumstances but a lack of a PPS number is definitely a barrier to care.

The number of providers is another issue. In particular, the low number of community providers in some regions of the country is a barrier to care. My Options is a fantastic service but it would appear that there is a lack of awareness about it, as Dr. Duffy covered in her report, among certain cohorts, despite the best efforts of the service. That is a barrier to care because people may then encounter community providers who are not transferring them on to another provider for their care. There are several barriers to care that emerged in the report that are specific to the early termination of pregnancy service.

I have one final question. Reference was made to the WHO's abortion care guidelines. Would our guests recommend that the Department of Health engages with experts in the WHO vis-à-vis those guidelines when drafting any upcoming legislation in relation to this?

Ms Marie O'Shea

In terms of the Department of Health, everything that it does should be evidence based. The WHO guidelines are evidence based so I would not see why the Department would not consult on them. How far it wants to take those guidelines is a matter for the Department. I cannot comment further because I would be giving a personal opinion, and that is not appropriate.

Dr. Catherine Conlon

If one thinks of healthcare generally, best practice in terms of healthcare is evidence-based care. In the context of a lot of health services in Ireland and a lot of health policy development, the WHO is seen as a gold-standard reference point, so why would it not be a gold-standard reference point in relation to this area of healthcare? One would it expect that it would be, so the Department engaging with the WHO on abortion healthcare, no more than any other healthcare, would be the assumption that we would make.

Dr. Deirdre Duffy

It is worth bearing in mind, apropos of an earlier point, that there is a large amount of evidence, data and research available to base evidence-based practice on and engaging on all forms of international evidence is central to any form of health service improvement and development. Engaging with the WHO would make sense.

Deputy Shortall is next.

Good morning. I thank our guests for coming in. It is particularly important that Dr. Duffy is here as well as Dr. Conlon because we know that there is very strong, evidence-based research accompanying the recommendations and it is very helpful to have both researchers here to answer questions.

Our guests' report was presented to Cabinet on 25 April. While this committee is engaging with the report and will, in due course, and hopefully quite soon, come to conclusions on that and report to Government, I would expect there would be a parallel process involving engagement by the Department of Health with the report's authors in relation to their recommendations. Can they tell us something about that engagement?

Ms Marie O'Shea

I have not had any engagement with the Department of Health since I met with the Minister, Deputy Donnelly.

That may have been just before it went to Cabinet, if that is what the Deputy is asking.

So, Ms O'Shea has not been contacted by the Department?

Ms Marie O'Shea

Not since then, no.

I cannot help thinking that there is a delaying process at play here to some extent. That is very regrettable. I would have expected that senior people in the Department - at least the officials - would have been in touch to clarify some of the recommendations with an eye to planning the legislation that was recommended. Has the implementation group that was established within the HSE to progress the operational recommendations been in touch with Ms O'Shea?

Ms Marie O'Shea

No. I did meet one of the members at a conference on conscientious objection. I know that the group has been established. That is my knowledge in respect of it.

That is very worrying, given the huge amount of work that has been done in this area. I am just wondering where that implementation group is getting its research from.

Ms Marie O'Shea

I would be very interested to find out what is going on. Certainly it is recommending a collective leadership approach to looking at guidelines for sections 9 and 10, which are very much needed, and also for looking at the problems that arise from the implementation of section 11, on foetal anomalies. I would hope that work is under way, even if I am not part of it.

It seems extraordinary. I take it the same goes for Dr. Conlon and Dr. Duffy?

Dr. Deirdre Duffy

I have received no further communication.

There has been no contact at all.

Dr. Catherine Conlon

We would have reached out the Department of Health and the HSE, and we did an extensive briefing on our study findings. We have done that, but we have not been approached to engage.

We will take that up separately. When I raised the issue of the proposed legislation with Ms O'Shea and asked if she thought it was possible to accommodate all of her recommendations in one Bill, she suggested that section 11 might need to be handled separately.

Ms Marie O'Shea

Yes.

She said that needed to be informed by service providers, service users, lawyers and ethicists. In what way would she see that recommendation being progressed if it is her view that that kind of representative body would have input into that? Who should initiate that and lead it?

Ms Marie O'Shea

I think the Department of Health should initiate it and lead it, because it is legislation and policy. It needs to engage with the main stakeholders, and the officials know who they are across the service providers. There is an organisation whose members are people who had to travel abroad for termination of pregnancy for foetal anomalies. They should certainly be on board. In terms of the legal implications of the survival of termination of pregnancy and what sort of care survivors should receive after they are born, it would be helpful to get legal clarification for them on that if it is needed. Quite often, it is very good to have the voice of an ethicist in a room to guide people. They are quite neutral, so they are always very helpful.

Dr. Catherine Conlon

I am not sure about the level of competency in the Department of Health regarding bioethics. There is a specific bioethics unit, but I am not sure that the level of expertise as regards bioethics within that unit, including dedicated and extensive bioethics experience, broadly and applied to this area, is in place as yet.

Ms Marie O'Shea

Dr. Daniel Nazum has written on palliative care in the area of perinatal care. He co-authored a book with service providers. His part of that book covers the right to palliative care of newborns who are born as a result of the termination of pregnancy. He is a very well-regarded academic at Maynooth University. He would make a good addition to the group if he were to be invited to join it.

Dr. Deirdre Duffy

Ireland has a specialist research group, led by Professor Keelin O'Donoghue, which is internationally recognised in palliative care in pregnancy loss. It is led by service providers and specialists. I believe they received international awards and recommendations from peer-reviewed bodies for their work in this area. Their inclusion within this group that has been recommended would certainly be valuable, but it is the Department of Health's decision, ultimately.

The other point Ms O'Shea made quite strongly when she was in with us perviously related to the uncertainty felt by service providers regarding where they stood relative to the law, and the fact that there had been no training on the provisions in the original Bill. Has she had any contact from any of the medical schools? Did any of them seek advice from her?

Ms Marie O'Shea

No. I cannot identify the institutions because I do not know, but anecdotally I hear that some education training is being built into the undergraduate curriculum. I do not think it is universal. I believe it is a minority of schools, but I do not know. It has started, but I am not quite sure what stage it is at.

Dr. Deirdre Duffy

What has emerged from this research and published research, and from research conducted by service providers and published in peer-reviewed academic journals and papers, is that the training that has occurred has been initiated and led by service providers themselves, for example, in cases of a group taking the initiative. No one has reached out to us.

Dr. Catherine Conlon

There is a concern around capacity demand there. There is a small group of providers providing this area of healthcare. They are also being left with the responsibility to train. I know the START group of GPs had initiated training for the GP cohort. I think we need to look at it. Dr. Duffy's study made an important point on the resource demand on those who are displaying conscientious commitment to providing this area of healthcare. They are also having to follow through on every dimension of it, including training. That is uneven in terms of the usual way healthcare would proceed.

Dr. Deirdre Duffy

Just to give an example of that, and it is noted in the report directly, one provider who is a bereavement specialist is generating and delivering training themselves on lunch breaks and in spare hours. A systemic approach is absolutely required. Implementing it would require resourcing, including capacity to lead training. It is worth mentioning that healthcare professionals have developed knowledge through delivering the service and are able to communicate back as would be normal with any form of healthcare, but capacity is key and there are impediments.

Sorry, what is key?

Dr. Deirdre Duffy

Capacity is key here. There are impediments to this, because delivering care and training others to deliver care is an additional component to a workload which is already full.

Sure, and it is getting more difficult to access. My final question concerns that training. Have the witnesses had any contact with the Irish College of General Practitioners in relation to it?

Ms Marie O'Shea

No, we have not. I am aware that it recently published guidelines for its own members on the management of the termination of pregnancy and the complications that come after that. That is quite a significant step forward. We should also acknowledge that national screening guidelines on ultrasound have also been produced. They contain auditable standards at the back. Organisations, hospitals and providers of that service should be supported to achieve those auditable standards. HseLanD is an on-site learning tool that can be accessed by people working in the health service. It now has a section termination of pregnancy. There are steps forward, but I simply do not know how they effective they have been. Work has been done.

Dr. Catherine Conlon

The Institute of Obstetricians and Gynaecologists guidelines that were generated before the implementation of the Act are still in draft form.

I call on Deputy Hourigan.

I thank the witnesses for their attendance. I will concentrate mostly on referrals and pathways to care. First, however, I would like clarification regarding the three-day wait and the first appointment. One of the witnesses said that if women ask for information during a session, that would be considered the first session under the legislation. Thinking back to the repeal days, one of the things that struck me was that so many people accessing this type of care are already mothers and already know what is involved in pregnancy. I am thinking of a scenario where I go into my local GP or another GP if, say, I am working in town, and I am just exploring options. Perhaps I have some complications or this is my third or fourth pregnancy. If I ask what my cut-off date is to make a decision, does that engagement count as the first appointment? I would like clarification on that.

Dr. Catherine Conlon

Yes. When women present to a health service, it usually involves making a call, saying they are pregnant and possibly saying they are seeking abortion care, although women usually do not use that terminology. They talk about exploring options.

Let us say they are asking for information.

Dr. Catherine Conlon

We found that "exploring options" was the terminology women used, and they were advised by the My Options service to use that terminology. A woman might have gone into the doctor not even realising she was pregnant and once it was established that the pregnancy was a crisis and she might possibly go on the pathway for abortion care, that engagement was deemed to be the first appointment.

If I were to ask about abortion at any point during that first GP appointment, under the parameters of the new legislation, does that count as the first appointment?

Ms Marie O'Shea

During the first appointment, there is a duty on the GP, for the purposes of the Act, to date the pregnancy or send the person off to get an ultrasound to date the pregnancy if that is appropriate.

That is really important in terms of the data. Most people who have already had children, and this new legislation may be coming into play in the middle of that process, would ask that question. I would have done it.

Dr. Catherine Conlon

It is an important point. Some people go in and they are really only learning about what the care entails in the first consultation. Then they have to make a decision. For most people, if the service is undertaken at less than ten weeks' gestation, they will self-manage at home. They have to think about how they put those logistics in place, including ensuring they have childcare and an appropriate setting. Some people are out of home or in house shares. They need to put in place the conditions that allow them to self-manage the care process. They must understand the care process and work out with their care provider - their GP - what is the most appropriate date to begin the process in order to be able to self-care through it. That is why retaining two fully funded consultations under the model of care is important. There were people who were fully informed, had read the HSE information and went into the GP appointment fully clear on wanting to progress and have the care administered on the same day, only to be told the three-day wait requirement prevented them from being able to do so.

To clarify, is it a question of trying to protect the right to reflect without impinging on access to care? I agree with Senator Clifford-Lee in that I find the current legislation patronising, condescending and demeaning. As somebody who goes to GPs for pregnancy testing, I feel degraded by the three-day wait requirement. It is really important that we clarify the issue and have a balance between protecting people's right to reflect and ensuring access to care.

Dr. Catherine Conlon

The language I would use would not be a "right to reflect". My language would refer to a right to attend a second fully funded consultation.

Perfect. That is really helpful.

Ms Marie O'Shea

I am informed by GPs that the first consultation takes 45 minutes because they discuss everything with the patient. The consultation also looks at the need for things like rhesus D testing if the pregnancy is to continue, whether the patient needs to go on contraception and the need for screening for sexually transmitted diseases. It is a very holistic form of care. It is not targeted at giving somebody mifepristone, which is the tablet to terminate the pregnancy. GPs believe that people want to know their own minds and that if they do know their own minds, their doctor should be able to give them the medication on that occasion. They say they can tell when people are uncertain because of the informed consent process and, where that is so, they advise the patient to go back and think about it, not just for three days but for however long it takes, provided they are aware of the cut-off point under the Act.

That brings us to referrals, pathways and all of that. In a previous session, we went into the My Options scheme and its deficiencies in understanding how many doctors really are providing care. It does not always do that. I am concerned about the situation of GPs who are struggling to provide care where that is not a reflection of conscientious objection but simply an issue of capacity. Ms O'Shea said the first appointment lasts an average of 45 minutes and then the State requires a second appointment. As anybody knows who has tried to get a GP appointment recently, it is difficult to do so. Is the three-day wait requirement doubling down on the capacity difficulties GPs may face in providing care? Is there a linkage there?

Ms Marie O'Shea

I think there is. The WHO certainly has stated that the need to return for further visits has implications for capacity and the use of resources.

Dr. Catherine Conlon

Another issue is the confinement of the professional clinician or health professional who is able to administer or prescribe the care to a GP. From the WHO perspective, there are competencies to administer this care among other health professionals, including midwives and nurse practitioners. That is another way in which the capacity of our health service could be looked at in terms of its ability to meet the need for this care.

That is my next question. Who in the multidisciplinary team can do it?

Dr. Deirdre Duffy

The point about continued capacity is a concern for GP providers. From our study, one of the things that emerged from the data was the concern of GPs about their continued capacity to participate as providers because of the burdens the Deputy mentioned with regard to having to make space for additional appointments and the amount of space it takes to continue to be a provider.

Is Dr. Duffy saying there are currently providers considering stepping back?

Dr. Deirdre Duffy

This came up in our survey data. A GP raised the point that the sustainability of continuing the role of provider is a capacity issue and this creates issues.

I can only imagine that issue is aggravated by the fact every GP is not providing the care and, therefore, the demand is more focused on particular GP practices.

Dr. Catherine Conlon

If we look at the GP list from the contracts office, we might see there are, say, 400 providing GPs today, but that situation evolves all the time. If a GP in a particular practice is the only providing GP, with no colleagues providing, when that GP goes on holiday or takes sick leave or maternity leave, he or she is removed as a provider. The list of providers is constantly evolving, with people opting in and out for various reasons, including capacity.

There are lots of attendees here today but if there is time later, I might come back in on primary care settings. For now, I have two more questions. One of the issues the witnesses cited repeatedly relates to waiting times for scans and referrals in general. One of the points in the document was that the HSE should conduct a national audit of waiting times between referrals and scanning appointments. Do the witnesses know whether that has happened?

Ms Marie O'Shea

I am not aware of anything the HSE has done in this regard. It certainly is an issue in some parts of the country. Some hospitals provide the service but the HSE has also contracted private entities to provide ultrasound scanning. In some parts of the country, it works really well. In other parts, there are problems in terms of referrals not being received, being overlooked, the sonographer not being available or other issues. Patients may ring up and be told either the hospital does not have the referral or they need to wait for somebody to come back from leave or whatever it is to do the scan. Meanwhile, time is ticking on.

Dr. Deirdre Duffy

As stated in the report and the literature review, there is one published study, by O'Shaughnessy et al, which undertook the type of review the Deputy referred to at a tertiary site and found a variation in times for referral. It is worth looking at the existing publications on this topic.

Dr. Catherine Conlon

In our study, it was described as a patchwork of services. When women go to a GP and are told they need a dating scan, they will be referred to a hospital. However, that hospital might only make scanning available to the abortion service from 8 a.m. to 8.30 a.m. on a given morning.

That is the only space for it.

From 8 a.m. to 8.30 a.m.

Dr. Catherine Conlon

Hospitals are having to make intensive resource decisions about that or they are referred to a private service, namely, Affidea, where contracted-----

Sorry. Is it more problematic with private services or is there no difference?

Dr. Catherine Conlon

The private services are not fully available throughout the country. Where Affidea is available, women will have to leave their GP practice, the referral will be sent to Affidea and they will have to go to the Affidea service. Affidea, as Ms O'Shea said, might have received the referral and when they get there - it could be quite a distance away - they have to go back, or the sonographer might not be willing to scan them, for example. There can be a number of issues. Our characterisation is this model of care has been a patchwork of services layered onto an overstretched health service. It has lots of wrinkles - or moments, as Dr. Duffy said - for time lags.

(Interruptions).

I am sorry, Dr. Duffy, but I need to move on. Our next questioner is Deputy Gino Kenny. I take it he is on the Leinster House campus.

I am. Five months ago when the report came out, Ms O'Shea said, in relation to the Taoiseach’s and Government’s response, that she was disconcerted and a bit of courage was needed in relation to the Government’s response. Does she still feel that way about the Government’s response to the report?

Ms Marie O'Shea

The Government's response to the report seemed to be premised on the idea that it would breach some contract it had with the electorate. I do not see that it had a contract with the electorate. I think the referendum was to repeal the eighth amendment and allow the Oireachtas to legislate for termination of pregnancy. In addition to that, the Oireachtas saw fit to put section 7 into the Act, which was to review the operation of the Act in three years. What was the purpose of doing that if the Taoiseach and Tánaiste regarded that as too short a time period to implement any changes that came out of it? That is my take on it. That is why I thought it was a bit disappointing and a bit of a bizarre thing to say.

Where does Ms O’Shea see it going from here? Obviously, there are diverging opinions, even in the health committee. However, there is an inbuilt mechanism in the legislation in that there is a review and so forth. Ms O’Shea made recommendations. Now it is up to the legislators - the Government - to make those recommendations come through. Where does Ms O’Shea see it going from here?

Ms Marie O'Shea

I would like to see the approach taken that it was genuinely a good thing to put section 7 into the Act to review its operation. When one looks at the Act at first sight, particularly if one is not trying to access or deliver service, the Act looks quite straightforward. However, when one delves into it, it is anything but straightforward to deliver, particularly sections 9, 10 and 11, and there are operational issues. I do not think that the public, knowing that, would want inaction on the Act. When you have that knowledge, you have to utilise it. The issues that came up when assessing the operation of the Act identified barriers and it is the responsibility of the Houses of the Oireachtas to address those barriers. I made evidence-based recommendations to help and assist the committee. I will continue, as will my colleagues here, to help and assist this committee and any other committee that wishes to have clarification or share knowledge. I would like to see some changes to the operation of the Act arising from legislative change and I hope what is helpful guidance to the HSE and the educational bodies as well.

I refer to the Bill of 2018. I note Ms O’Shea stated in the report that it could be open to individuals to take the State to court in respect of the restrictions, particularly around certain aspects of that. I do not know if that is in train or if that has happened since the legislation was-----

Ms Marie O'Shea

I am not aware of any actions that have been taken. I refer to the Whelan and Mellet cases. It has to be clear to a person when they are eligible to receive abortion and it certainly is not clear under the grounds of sections 9 to 11, inclusive, and I think that is potentially challengeable.

In Ms O’Shea’s opinion, a case like the Mellet and Whelan cases could happen again.

Ms Marie O'Shea

In theory, it certainly could happen again.

To Ms O'Shea's knowledge, there has not been any kind of-----

Ms Marie O'Shea

Not to my knowledge, no.

Okay. That is it.

Dr. Catherine Conlon

I wish to add to that in terms of people trying to access care, particularly under section 11, there was a sense among those we spoke to in our research that the testimonies during the repeal debate from people who had sought termination for medical reasons had been very instrumental in moving the public – the Irish citizens – to vote for a reform of the law on abortion. This group of women found that when they actually went to access care under that legislation, it was very difficult. Of the 12 people we spoke to, four accessed care in Ireland and the others had to travel abroad if they continued to wish to access care. They felt it was a breach of what they understand the law and referendum to be about. The operation of section 12 from the service user perspective is not honouring the spirit of the referendum.

Dr. Deirdre Duffy

The best bit of referendum, from evidence-based medicine and evidence-based practice, was to introduce this as a form of healthcare. Essential to any form of healthcare is ongoing review, feedback and development to ensure continued excellent services. Section 7 is a welcome step but evidence-based medicine requires ongoing, consistent and regular review as well as a feedback loop to identify areas of improvement and developments. If the promise was treating it as a form of healthcare, then it is necessary to at least show what steps have been taken and the effect of those steps.

Ms Marie O'Shea

To illustrate the point, service providers and service users said that when it comes to foetal anomaly, they were being told where the foetus is affected by a condition:

We do not think it will survive birth and even if it does, it will not live long after birth. However, we cannot say how long it will live - whether it will be 28 days or not.

That is not a clear ground for somebody to understand whether they are eligible to receive abortion services. The Act lacks clarity and that is why it is open to challenge at international law.

Dr. Catherine Conlon

People we spoke to from Ireland who were seeking abortion care for foetal diagnosis reasons were faced with a diagnosis of a severe life-limiting anomaly. They were very conscious they were going to give birth to a child with that diagnosis in the context of a State that has very limited social and healthcare supports for families raising children. At the time we were interviewing people for the study, there had just been a “Prime Time” documentary about the pressures parents are under. The parents interviewed for “Prime Time” said that they were feeling suicidal because of the strains and pressures of them raising children who had severe anomalies at birth. The people we spoke to were making their decision and being faced with a diagnosis of that order, considering their capacity to raise a child, the quality of life that child would have and their capacity to continue to care for the children they already had. To have this blunt instrument in the Act that said a certainty of a clinically determined 28 days did not in any way, according to the women we spoke to, meet their need for termination in the face of a severe foetal anomaly diagnosis.

Five months ago, legislation tabled by Deputy Bríd Smith passed Second Stage. Therefore, there is a clear message from the Oireachtas that the recommendations Ms O'Shea made - and beyond - need to be legislated for. Between Ms O'Shea's report and the legislation passed in late May, there is a clear appetite to move this on.

My instinct is that the Government is quite opaque about this report, to say the least. The Government is under an obligation to legislate but, as was said, this requires courage and needs to reflect the views not only of legislators but the general public.

I want to take up Deputy Kenny's last point. We have not finished our work here, so the Government is waiting for us. I am envious of colleagues who can be so definite on these issues. I remember attending a pro-life meeting as a public representative during the protection of life in pregnancy legislation, defending it and explaining it as best I could. At the time, there were a huge number of people coming into clinics in relation to that legislation. There has been a lot of debate on this matter which of course led to the campaign. I voted "Yes". I was somewhat comforted by the three-day wait period. I raised this issue the last time Ms O'Shea was here. I mention the responses to parliamentary questions by Deputy Carol Nolan on the number of women who did not go ahead with a second appointment. Ms O'Shea said that some of those women would have had miscarriages. She is suggesting the Oireachtas change that. How many women who did not go ahead with the second appointment went on to have children?

Ms Marie O'Shea

I do not have data on that.

Did Ms O'Shea attempt to get the data?

Ms Marie O'Shea

There is no data on it. I have explained this to the committee.

Yes, this is the problem. This is the one of the issues I have. I know Ms O'Shea said the last time that she could not assume that pregnancies resulted from this.

Ms Marie O'Shea

As I understand it, this data is coming from the PCRS office and is based on GPs claims for one visit only. There will be a claim for one visit only if the woman was over nine weeks and six days pregnant. At that point, they have to get referred to hospital. Those numbers are in there. Theoretically, the number of people who perhaps attended a different GP because they did not like the approach of that particular person or that particular person was not available on another day are in there. Women who miscarried are also included. We have the research that the IFPA did. That showed that only 2% did not return for a second appointment. During the study, it would have been impossible to do a retrospective piece of research on why people did not attend and I addressed that to the committee earlier on

I would counter that by saying that is critical. If Ms O'Shea is asking-----

Dr. Catherine Conlon

We are conflating a mandatory three-day wait. Earlier, we described the circumstances under which someone may enter into a first consultation under this model of care. A woman goes in, discovers she is pregnant and begins the discussion and that is deemed to be under this model of care. Alternatively, a woman knows she is pregnant, has decided that she is going to proceed with an abortion and goes to have the consultation. There is a huge spectrum of people, between the person who goes in and has a consultation under this model of care without even knowing they are pregnant and the person who goes in with absolute certainty.

If we take the position that we want a form of healthcare that allows people to come in, have a full consultation, as Ms O'Shea said, with a holistic orientation to it and at the end of that consultation make a decision that is fully informed and that their healthcare professional provider can see is fully informed, and then can decide that they want to proceed with that healthcare, that is one possible outcome of the consultation.

In many cases, where a person visits a GP and has a conversation about healthcare, they might say they are going to return. They may return to proceed with the care discussed or they may decide not to do so. For my purposes, it is a quality outcome and a caring health system when any person who makes an informed decision as to whether or not to proceed with healthcare feels fully supported and has access to the care they wanted.

If we are saying that a legally mandated intervention would be put on any person, no matter how certain they are, no matter how close they are to a cut-off point, no matter what their logistical needs, and no matter how stressed and traumatised they might be by the pregnancy, that is not a compassionate, caring, quality health service. What we are saying is that only a legally mandated three-day wait will allow for women to make competent decisions. However, what I am saying is that women can make competent decisions in a model of care that allows them to have two fully-funded consultations in conjunction with healthcare professional who can determine whether they are making informed consent or not. If we are saying in an authoritarian way that only a mandatory three-day wait will ensure a woman who is seeking an abortion can make a competent decision, that is undemocratic and unfair.

I do not doubt that every woman is able to make a competent decision. I am not arguing the point. I am asking is there evidence of how many women went on to change their minds. That is the issue.

Dr. Catherine Conlon

As a social researcher, I would be the person who would have to do that research. The first thing I would have to do is go to my university ethics committee and ask if I could go back and speak to people who attended a GP and who did not return for the second consultation. First of all, there is GDPR. Any research ethics committee in the medical domain will not allow me to access the names and details of people who attended for the first consultation. I then go to public awareness-raising and say that I wish to speak to people who attended for a first consultation and voluntarily did not attend for a second consultation and to volunteer for my research. The ethics committee then has to determine, as Ms O'Shea said earlier, whether it is ethical that I ask a person about that particular moment in time when they went to a GP in distress about a pregnancy and about the moment in time when they made the decision not to return. I have to ask them to talk about a moment in time in their pregnancy when they were considering termination that they have now continued and they possibly have the child from that pregnancy in a cot in their home where I am interviewing them. I would not expect that of any ethics committee. Our experience is that no ethics committee would see that as an ethical practice.

When the Senator says the research has not been done, I wonder to what extent he is aware of what is entailed in doing that research, both from the practice of the research as a social researcher and from the perspective of the participant. Our main ethical dimension as a social researcher is to do no harm. If we are to ask a person who has proceeded with the pregnancy to sit and revisit the moment they were with a GP and considered termination, I am not sure that it is not doing no harm. We have to be really aware of what we are asking for when we are saying that research needs to be done.

I appreciate that. Those are valid arguments. At the same time, for me, making a decision, I believe in data. I appreciate that it may be difficult to get it.

Ms Marie O'Shea

It could be difficult. It would be more possible in a more blended approach to establish the reasons people are undertaking terminations of pregnancy and what the factors behind it. One might discover it in that context.

Dr. Catherine Conlon

We have a model. After the X case, the Department of Health commissioned a piece of research called the women and pregnancy study. I was a member of the research team and Dr. Evelyn Mahon from Trinity College was the principal investigator. In this research, we interviewed people who had travelled from Ireland to Britain and who had opted for an abortion. We went into eight antenatal clinics in Ireland. We spoke to people receiving antenatal care about their pathway to that care. At the time, there were still some institutional homes for people seeking adoption. We spoke with people in Bessborough who had chosen adoption and to people who had chosen adoption through other routes. There is a model there for research about all the different pathways to different options around pregnancy outcomes. If the Department of Health wanted to replicate the study, it is a very good, well reviewed and well regarded model of research.

To say it was only homing in on the individuals who attended for one consultation considering abortion and then opted out is unethical, however. The much more holistic approach that was taken by the women and pregnancy study published in 1998 by the Department of Health took might be a model that we-----

The numbers are based on PPS numbers. I do not see that if a person went to one GP and another GP or one GP and went to hospital-----

Ms Marie O'Shea

No, I am talking about how-----

I presume those data can be made available.

Ms Marie O'Shea

I am talking about the data on the numbers who attended for one visit only. To my understanding, that is based on the numbers of claims for payments by GPs for remuneration for providing the service that-----

Are the figures not accurate?

Dr. Catherine Conlon

If we had----

Are they not accurate?

Dr. Catherine Conlon

If we had a data collection system that asked GPs to give a full account of the actual visit, that would be preferable. If a GP is referring a person who has had the first visit with them to hospital, if they record it on the return as “person referred to hospital”. That explains that return for one visit only. We could do it by asking GPs to give an account of their return for one visit only. That would be a more ethical way to do it. GPs should be asked why are they making a return for one visit only. That would be the most sound way to do it.

Ms Marie O'Shea

Or what happened after with-----

Sorry, does Dr. Duffy wish to come in?

Dr. Deirdre Duffy

On gathering data and the value of data, there is complexity here. Trying to interpret the exact reason a person made a decision to continue with a pregnancy is very difficult and may involve retraumatising a person about a very vulnerable time in her life. An ethics committee - I sat on an ethics committee in a health research department for many years - would not approve that study.

Ms Marie O'Shea

I understand and hear the Senator that he was comforted by the mandatory three-day wait but what is being proposed is not taking away a time for a person to reflect. As I stated, the Houses of the Oireachtas have a duty of care not only to people who might change their mind, but also to people who are currently being adversely affected by that three-day wait, as outlined in the report.

Okay. I thank the witnesses.

I thank the Cathaoirleach for allowing me to contribute and the witnesses for attending the meeting. We have just had an important interaction on the difficulties of data compilation and the inferences or attempt to take an inference from figures. It is important to state that when the law was being drafted, we did not know how abortion practice was going to play out in this country. We now have the benefit of hindsight in that regard, yet there is still much to be done in respect of research. We have the IPA research, to which reference was made. In terms of the evidence gap that is being used to kind of cast a cloud over the proposed changes, have studies which have been done well been carried out in other countries with regard to the decisional certainty, if I may use that phrase? It would be helpful to know whether that research has been done elsewhere. I believe it has, but I would like to hear from the witnesses in that regard.

Dr. Deirdre Duffy

The Senator is asking about research on the decisional certainty of people when they enter-----

Dr. Deirdre Duffy

I will come back to the point made by Dr. Conlon on this. The Department of Health needs to look to a study of the vast amount of data that are available on how people make decisions.

Dr. Catherine Conlon

To my knowledge, there has not been extensive attention given in the international literature - neither clinical nor social research - to the assumption that women have a decisional incapacity around abortion. Although the issue of decisional certainty and the use of this has been homed in on in the debate here and on the legislation more generally, as well as in our terms of reference, it has not been a concern to any large extent for the international literature, either clinical or social research.

That is important to-----

Ms Marie O'Shea

The greatest piece of research underpinned by evidence of which I am aware is the WHO abortion care guidance. That is completely underpinned by research and it is very much against the imposition of mandatory waiting periods. I do not think one would get better than that, to be honest.

I thank Ms O’Shea. The report details the patchiness of service or coverage across the country at GP level. I wish to ask about the GP contract and the number of visits entailed. What do we know about the refunds GPs are seeking? Do we have data on the one visit and two visits and the follow-up visit? Is the contract tied into section 12 of the Act? I am trying to work out whether there will need to be negotiation with GPs if changes are made or whether we can ensure the contract remains in place even if there are changes to the legislation. I do not know if the witnesses have considered that.

Ms Marie O'Shea

The GP contract prices each visit individually. I cannot remember what each visit costs but if a person were to attend three visits, the payment is €450. It specifies visit 1, visit 2 and visit 3. Obviously, GPs are bound by the legislation.

It is €450 in total.

Ms Marie O'Shea

In total, yes.

Are changes to that contract needed to-----

Ms Marie O'Shea

I did not hear any GPs talk about changes to the contract. I had-----

-----incentivise more GPs to come into-----

Ms Marie O'Shea

I think they were quite satisfied with the remuneration. They regarded it as fair and-----

Are changes to the contract needed to incentivise more GPs or are there other factors?

Dr. Catherine Conlon

My understanding is that the contract is there as a contract between providers consistent with the Act, as Ms O’Shea stated. It is the contractual space. One of the things GPs would say is that not having capacity pressures would allow them to opt in more. Normalisation of abortion as healthcare is the other thing. That is a cultural piece globally. There is the issue of lack of contestation and clarity. A big piece GPs have said is if their local hospital was an abortion-providing hospital, that would gives them greater certainty that they have a referral pathway. It is more a logistical and infrastructural piece to better resource and support and implement the service, rather than being an issue with the specific contract with GPs.

The report documents the strain and capacity issues very well. That point about the proximity of the hospital providing its own services is crucial. My apologies if these questions have already been asked. The witnesses referred to having a broader range of medical professionals. If capacity is one of the chief issues that is causing a constraint, what is the thinking behind that statement in respect of a broader range of medical professionals?

Ms Marie O'Shea

The predominantly method of abortion in Ireland under all sections of the Act is a medical abortion, where a person is given mifepristone, a hormonal drug which actively terminates the pregnancy, followed by misoprostol, which is a drug to eliminate the products of pregnancy. The Act stipulates in lines 10 and 11 that a termination has to be carried out by an obstetrician. That is not any doctor. It cannot be done by a non-consultant hospital doctor, NCHD. It must be done by a consultant. That is one barrier. There is difficulty recruiting consultants in some areas.

We note that for multifaceted reasons there are difficulties in the geographic coverage of GPs. The WHO would say very clearly that it should not be confined to the medical profession. Certainly in a hospital setting, why could a junior doctor, midwife or nurse not give mifepristone to a patient? Why even in a GP setting could the practice nurse not give the person mifepristone? It might get a bit more complicated if we took it out to pharmacies. They already dispense the morning-after pill. It could certainly be broadened out to take pressure off the medical profession quite safely.

Ms O'Shea is aware of other jurisdictions----

Ms Marie O'Shea

Absolutely, yes, in New Zealand it is.

Dr. Deirdre Duffy

New Zealand has a community-based care model where they use task sharing, as do Colombia and Argentina, and I believe in India they have also progressed. These are using in-the-community care which would be midwives and, in India, would include pharmacists. There are models of care which have been reviewed and which are supported by the health service as part of shared care pathways. It would seem from the data that was produced as part of this study that it would be the logical next step to move from a consultant-led service towards a broader range of health professionals.

Sure, both within primary care and acute hospital settings.

Dr. Catherine Conlon

The WHO guidelines from 2022 give extensive attention to that.

I sense a degree of frustration from the witnesses with some of the politicians. If I can attempt to frame it from my own perspective, it is in the context of the comments about the normalisation of abortion as healthcare and the global challenge with that. I can identify with that. Clearly, and I mean this is a very positive way, the witnesses have got their heads around that. Culturally there is a shift or movement in that direction, as reflected in the referendum. There is a piece of me that has a foot in both traditions, the strongly cultural piece and the direction in which we appear to be moving. My questions are based on coming from that. I am also on the Oireachtas Committee on Assisted Dying. We have had some amazing witnesses over the last three or four months speaking about different systems that are in place. It is very interesting culturally to hear about where some societies are. This is the first conversation we have had about that. It is in that context.

I understand the inputs in respect of the three-day piece. I am taken by the evidence our guests are presenting today and the evidence we received from other bodies. I accept that the rigidity of it is an issue. I do not accept the rigidity of the three days as being a thing that ought to go on, necessarily. I accept what our guests are saying about the rigidity it imposes. Do they also accept that if it is broadened too much, we are potentially drifting into a much broader interpretation of the timespan in which terminations are allowed?

I accept what our guests say about the research. It is valuable input that it would be very difficult to carry out. I think Senator Kyne was coming from the right place in asking if we have any figures suggesting that. I am also taken with one of the inputs from the National Women's Council on conscientious objection and its monitoring. I have raised it in this committee. There is an issue when the State passes a law. We did see that in respect of availability, which I think will probably increase over time. If any of the legislation around this was loosened, where do the witnesses see practitioners going in terms of conscientious objection? The National Women's Council raises this in page 6 of its submission to us, stating that the Medical Council's guide to professional conduct and ethics for registered medical professions is clear that in cases of conscientious objections, patients should be informed that they have a right to seek treatment elsewhere. Doctors must facilitate the transfer of the patient to an alternative provider. What is the experience of our guests in terms of that actually happening? I was very concerned about it in the early days of the reports.

I will come to my final question. I accept what the witnesses are saying about the rigid gestational time periods. The reason I referred to the assisted dying committee was not to compare but just about the structure. Legislators are conscious of the issue of what people voted for. Is this what people had in mind, to actually loosen things? I think the witnesses make a very compelling case on the rigid gestational period. Do they understand the challenge that poses for some legislators? If we loosen it----

Ms Marie O'Shea

I totally understand the challenge for legislators. I have very close friends who, I do not know why, since the commencement of this review have come to me and said they voted against it, expecting some sort of reaction from me. Of course there are always going to be divisive attitudes towards termination of pregnancy. That is a fact of life. We are talking about amending section 12 and people are asking if it is an effort to extend it beyond the 12 weeks by stealth almost. The proposed amendments are really trying to accommodate people who present later in pregnancy for whatever reason. There are those who have presented within that 12-week timeframe but the services cannot be put in place to deliver the care they need. There are also people who, having taken mifepristone earlier in the pregnancy, have had a failed termination of pregnancy. It is a teratogenic drug; I think there are 35 known limb defects that are associated with teratogenic medication. They may present either towards the very end or after that 12-week period. There is a question as to whether it is ethical to enable that person to continue their pregnancy. I would argue it is probably unethical to say that they have to continue a pregnancy in those circumstances.

Can we go back on that piece?

Dr. Deirdre Duffy

If the Deputy would like me to clarify, if a termination has been unsuccessful, but the person has taken medications, teratogenic means the medications will have had an effect on the health of the foetus. Effectively, a clinician could have prescribed, in accordance with the legislation as it stands, a medicine that could harm the foetus, and then later in pregnancy somebody finds that the termination has not been successful, they are still pregnant and now there is foetal harm of unknown consequence. Through this rigid gestational limit, a question is created over whether somebody can complete as they pursued or if they have to continue having taken a harmful medication.

And the criminality piece.

Ms Marie O'Shea

Also if we look at the recommendations for law change around section 12, in each of those recommendations the person has presented to the GP and-or the hospital before the 12 weeks have elapsed. That is the difficulty. In terms of monitoring conscientious objection, I think it would be difficult in practice. As I outlined in the report, Professor Fergal Malone, who has appeared before the health committee on many occasions, thinks it would not be a good idea.

If a person were to know what their stance was on termination of pregnancy, it might put them under some pressure or unease when they are making their decision, if they thought their decision to continue or discontinue was at odds with what they perceive their clinician to be thinking. A better idea, and one put into the recommendations, is that the HSE would map providers. It would go into the community and see exactly how many people are providing the service in the community because one contract could have more than one provider if it is a contract with a practice. To also go into-----

When Ms O'Shea says mapping, does she mean mapping by identity?

Ms Marie O'Shea

No. I am just suggesting finding out the numbers and also going into the hospitals to see how many neonatologists are willing to provide the service - without naming them - and how many obstetricians in each area.

Has that not been done?

Ms Marie O'Shea

It has not been done. I raised a question with the National Women and Infants Health Programme, NWIHP, and then with the chief commercial officer to see if they could identify how many providers were in each particular unit, but they were not able to do so.

Dr. Deirdre Duffy

It would relieve some of the capacity issues in acute care to have this on a confidential basis to highlight that this would be an ordinary part of mapping what resources are available to ensure that in case of emergency there is someone available who is willing to provide the service. This is about relieving those pressures too.

Dr. Catherine Conlon

On the conscientious objection piece, the ethical framework of Irish medical organisations, which govern clinicians' medical practice, addresses this issue. If a person has a conscientious objection to providing any form of healthcare, if that is in place and if a person presents for that form of healthcare, the clinician is ethically obliged to refer that person on for care from another provider who is willing to do it. The review report is recommending that this be placed on a statutory basis, if I am correct.

Ms Marie O'Shea

It is already on a statutory footing but because the statute imposes an obligation on the person to "transfer care", which is the wording used-----

Dr. Catherine Conlon

What we found and observed in our study was that some people were actively obstructed in accessing care.

How were they obstructed?

Dr. Catherine Conlon

The most tragic or difficult case we came across was that of a young woman who had been the subject of a sexual assault. She attended her GP with symptoms and discovered in that consultation that she was pregnant. The GP, who was her family GP, advised her to engage with the pregnancy counselling service. She came back to that GP and they had a further conversation. She said she was clear at that point that she wanted to proceed with a termination. The GP did not say he was not a provider of termination care but asked her to return to have another session with a pregnancy counselling service because he felt she was not clear in her decision. She returned a third time to that GP believing she would be cared for. Obviously, her time was moving towards 12 weeks. The GP told her on the third visit that his practice did not provide the care nor did they agree with abortion care being provided and they would not give her any information as to where she could access care. Thankfully, she found her way to a women's health clinic in Dublin within the 12 weeks. They referred her to hospital for care and also to the sexual assault treatment unit. The GP practice had not provided her with care for the sexual assault either. Their sole focus seemed to have been to obstruct her in accessing abortion care. To me, that is the most tragic way that this aspect of our health service and the abortion care service can unfold. There were other people. One woman who lived in the west of Ireland had gone to seven GPs. She was a non-national woman who was trying to navigate the Irish health service for the first time to access abortion care and she made seven contacts with GPs - with receptionists or GPs themselves - before she was connected to the My Options service. The stock answer she got was "we do not provide that kind of thing here" and one receptionist asked her why she would not continue her pregnancy.

Ms Marie O'Shea

When we are talking to the Act, I mention the recommendation that there would be a regulation against a healthcare professional providing misleading information. That has certainly occurred, as evidenced in the Unplanned Pregnancy and Abortion Care study, which found that people are being told they are earlier in their pregnancy than they actually are. Anecdotally, I hear from clinicians as well that this is not an irregular occurrence.

I need to suspend the meeting now. We will have a comfort break for ten minutes or so.

Sitting suspended at 11.25 a.m. and resumed at 11.40 a.m.

Senator Kyne was trying to establish something legitimate with his questioning about the three-day period. While the reasons given by the witnesses for not being able to carry out effective research on that are legitimate, they do not take from the point being made by Senator Kyne. As legislators, we need as much data as possible. While we can find reasons not to do it, we can also find reasons to do it. I do not want a discussion on it, but I want them to reflect on it. Senator Kyne was on point in his line of questioning, and the witnesses were probably a little too defensive in their reaction to him. The matter merits reflection.

I will move on to the question I would like to pose. From their research and medical knowledge, is there any other example in Ireland or anywhere in the world where there is a three-day delay for any medical procedure?

Ms Marie O'Shea

A mandatory three-day delay.

Ms Marie O'Shea

Not that I am aware of.

Would Ms O'Shea agree with me that it is disrespectful to women?

Ms Marie O'Shea

Service users and service providers say it is patronising and potentially harmful to their psychological health, that they are assumed not to have the capacity to make that decision.

I agree. If nothing else comes of this review we need to deal with this three day delay. Whatever one's view is on these issues, I suspect no woman in the world makes the decision to go to a medical practitioner for termination without thinking long and hard about it.

Dr. Catherine Conlon

In regulating abortion care in other jurisdictions waiting periods are enforced. On Senator Kyne's question about research on the three-day delay, we proposed two models. There was the women in pregnancy study model from before, and having GPs record the reason for the single return. To reiterate, they are two possible designs.

That is important. Following on from Deputy Shortall, I will develop another point, which is the witnesses' engagement with the Department of Health since they made their report available. They met the Minister once. Has there been any other scheduled meeting with the Minister?

Ms Marie O'Shea

No, nothing. There has been no engagement at all.

Has there been any engagement with the Department of Health or are there any plans for an engagement?

Ms Marie O'Shea

It has been silence.

That would tie into the fact that the review was left to the very end of the legal period enshrined in the legislation. It was quarter 4 of the last year. Would it be correct to say that the Department of Health, and by extension the Minister, is actively delaying doing anything about the implementation of the report? They are actually using the Joint Committee on Health as an excuse to delay it, where it should be a parallel process.

Ms Marie O'Shea

I cannot presume to know what they think.

What is Ms O'Shea's view?

Ms Marie O'Shea

When I was undertaking the report it was supposed to be completed in November or December of last year. However, that could not happen because of various issues in terms of the completion of research and projects. I can say I was under extraordinary pressure at the start of this year to deliver this report to the Minister for Health. So much so, that I almost thought there would be somebody standing in my front garden on a Sunday to grab it out of my hands. That is the degree of pressure I was under. I know since then the Department has sent it to this committee. I would have hoped the Department of Health would at least have started convening various groups to look at guidelines for regulation.

None of that has happened.

Ms Marie O'Shea

Not to my knowledge. I simply do not know.

At this point, does Ms O'Shea have any confidence in the Department of Health?

Ms Marie O'Shea

I would like to think I do. I am an optimist by nature.

That is okay. In terms of this issue, I just have to wonder what is happening. Perhaps we might have some engagement with the Minister. Many of the questions I was going to ask have already been asked. I am frustrated with the delay in progress from the Department of Health's perspective. I feel it has just been thrown over to this committee and left with us, whereas there should be structural engagement. There should be some protocols or processes within the Department to at least implement the non-contentious areas of the report.

Ms Marie O'Shea

Given the pressure I was under to deliver the report that it was going to be action stations.

Dr. Catherine Conlon

Speaking as a social policy academic, we look at the procedures around policy-making and good policy-making practice. You should have an extensive evidence base, and consult with key stakeholders. The report recommended a multidisciplinary led decision-making process. You would expect movement to have been made on those. I reiterate concerns about the unit in the Department of Health. What is the staffing infrastructure of that unit? This area of abortion care is under the bioethics unit of the Department of Health. I am not sure what the resource attachment is to that unit, including whether or not there is a bioethicist. An important thing to look at is the capacity and staffing of that particular unit. If it were staffed more adequately or appropriately it might facilitate things moving on. I do not assume that the Department is willfully ignoring the research. It may be down to capacity there too.

I appreciate that the Department of Health is probably the most pressurised Department. At the same time, this issue is an extremely important one. As Ms O'Shea has said, the pressure they were under to deliver the report in a timely manner has not really been reflected by the follow on actions.

I welcome our witnesses and thank them for their dedication and report.

I want to clear up a couple of things. There was a suggestion in some of the responses we got that politicians were not possessed of knowledge of the real issues to deal with this subject, which I believe in the first instance is an issue of women's health. I reject any suggestion that as elected representatives we might be inadequate in our intellectual capacity to deal with a subject of this nature. We deal with it all of the time. We have to, it is part of our work. We do it as best we can. It might not necessarily be to the high standards people would expect, but it is what we do. I am worried about a certain aspect of the report. It would appear that the report was conscious of the need to extend and expand the legislation to accommodate a need other than the needs that were presented to the committee prior to the referendum. I want to settle that and point it out. Women's health was the primary issue. We all dealt with the issues. I dealt with more than an average number of them that had tragic consequences, not as a result of my intervention but as a result of the intervention or lack of intervention on behalf of some professionals. The fact of the matter remains, insofar as I am concerned it is still a matter of women's health, and the issue of the three-day wait, which seems to have been presented as an obstacle to women's health. We extensively interviewed people who pointed out that the non-existence of a waiting period was a factor in what happened afterwards. They presented their case in a factual and evidential way and to the best of their ability in the way it affected them before the advent of legislation.

I want to point out that it is a women's health issues insofar as medical abortion, which was available at the time, had certain connotations.

It was unsupervised, it was readily available and there was no approval or suggestion of oversight of any pre-existing medical conditions or, for that matter, mental conditions. It was necessary to create a space, such as the three-day wait, which was the best that was available at the time, in order to enable the woman or girl, as the case may be, in making her decision, which she is entitled to do. We should not make the decision for anybody – man, woman or child. That is something that is readily available and constitutionally available to the woman, man or child, whatever the case may be.

I want to emphasise that with regard to this particular review, the purpose of which was look at how it was working, not the extent to which it was working, which is important. I get a steady stream of communications from people who say that this is not what we voted for, and they have a right to raise that question. They might be wrong, like politicians are sometimes regarded as being wrong, but they may also be right. They claim this was on the agenda all of the time and that it was a question of just getting one part of it passed by referendum and then to wait for the next part. That was not our job at the time. I believe we did our job as well as could be done anywhere in any other country in Europe, and I think it was effective.

We are now in a situation where we need to ask the question as to whether women who had a concern – they were either pregnant or thought they were pregnant - would go to their GP to ascertain the extent to which and how they should proceed. It was not a question of whether they should go to another jurisdiction for an abortion; it was the extent to which their needs could and should be met here. That still remains and, to my mind, it has not been answered yet. In the case of those who went to other jurisdictions for a termination of pregnancy, we do not know enough about the reasons they went there. For example, were they from that jurisdiction originally or were they going for privacy reasons to another jurisdiction? That is what we discovered to be the case in some of the situations we dealt with. The issue still continues. Those of us who were there then, prior to the referendum, need to be satisfied that what we are talking about is one and the same thing. Is it the woman's right to have the maximum amount of information and her right to decide which way she wishes to go? She listens to the information put to her. If the information laid in front of her is not adequate, then it is necessary to provide that and by one means or another to establish her right to have that information.

I have suggested in the past, with no respect to Ms O'Shea, that the report is a considerable step forward from what we passed in the referendum and the legislation that was published before the people. One thing that politicians are always aware of is being caught out. Very often, we see things happening in the country that should not happen, and because we did not speak up or raise a particular issue at the time, we are seen to be lax in the way we go about our duty. These are important issues. I do not think this is about an extension of the legislation because that would be challenged. I know it has been suggested that it cannot be challenged in a court but, of course, everything can be challenged in a court, and it is wrong to suggest it cannot be. That is what lawyers do for a living, and they have a right to do that as well.

I want to be reassured that there is no intention in respect of the three-day waiting period other than to provide the woman with the maximum possible amount of information relative to her situation and condition, her concerns and her worries. The availability of that advice is something that we can and should question, and our witnesses should question as well, with regard to why it is not happening to some extent and who has decided that it should not happen. The committee questioned this strongly at the time and we were reluctantly given an undertaking that this information would be made available without interference. We still need that and I would like to see some reference to it.

There was a reference to politicians’ intelligence, Chairman, but I would not-----

I noticed you were looking at me when you mentioned that. Can we have a response?

Ms Marie O'Shea

Of course. The Deputy raises a couple of points. I am certainly very conscious of the amount of work that went into formulating the legislation, passing it through the Dáil and commencing it, and I am not ignorant of that.

With regard to the terms of reference that I was given from the Department of Health, I disagree with the Deputy. My terms of reference were to assess the extent to which the objectives of the Act and the regulations have been achieved, having regard to three key information strands concerning the service user, the service provider and the general public, and then to explore and weigh the evidence for and against any proposed changes to this Act from the service provider with respect to a service user perspective and to give a report to Government. I do not think I have stepped outside my terms of reference in producing this report. It is what the Department of Health looked for and it has been delivered in a fair manner.

I understand what the Deputy is saying about the three-day waiting period and people perceiving that there is value to that. What is being proposed as a change in the legislation is not jeopardising people's ability to reflect or delaying their care whatsoever. The model of service will still stay as it is. There will be two visits to the GP that are free of charge and the GP can advise that people are fully entitled to return on another occasion, whether that is to give the issue more consideration or whether it is-----

Have we evidence of where they did not advise?

Ms Marie O'Shea

At the moment, the structure is that they have to come back for the second visit so we really could not go into that.

What of cases where they did not advise because of that?

Ms Marie O'Shea

We cannot go into that. I am told by GPs that where people are not sure or come across as not sure of their decision, the GPs direct them to counselling services. I have spoken to One Family, which runs the My Options helpline. When they go to counselling services, the advice is along the lines that if they were to have the baby, these supports are available and X, Y and Z. It is not simply guidance as to how to procure abortion and it is also guidance as to various resources that are available should they continue the pregnancy as well. I am satisfied, both from the work I did and the people I talked to, that information is freely available to them out there and the State covers the My Options counselling.

No, that is not-----

Deputy Durkan had ten minutes, and he used eight for his questions. Can we have a reply from Dr. Conlon?

Dr. Catherine Conlon

At no time during my contributions to the committee did I ever intend to suggest that any Member of the Dáil had any lack of intellectual competency to consider this issue. In fact, in the participative democracy process that Ireland undertook in terms of the constitutional review process during the citizens’ assembly, we had an incredible model of participative democracy around reform of the abortion legislation. The citizens’ assembly, followed by the parliamentary report, was an exemplary process of reform. I am very proud as an Irish person that that is the approach we took, and I think the Oireachtas did us proud on that.

In referring to the statements people would have made prior to the referendum about the sense of feeling pressurised to follow through with an abortion, I did research, funded by the Department of Health the HSE, with people from Ireland who had travelled to Britain for abortions on two occasions in the 1990s and 2005. One of the things that was clear was that given the actual commitment of having to travel to Britain and to be in that clinic, your capacity to feel that you could opt out of pursuing that decision was much more difficult than if you attend an Irish GP local to your home, have a conversation with the GP about your possible options, know that you can come back at least once, if not more, and continue a discussion with them supported by a funded counselling service, which we also have under the Irish system.

That makes for a very accessible abortion service. Our statistics internationally show that a holistic, accessible abortion service reduces the rate of abortions because people are able to be fully informed, they know that the service is available and accessible to them but they also know that they have other supports available to them. The legislation-----

(Interruptions).

I am sorry, Cathaoirleach.

Dr. Catherine Conlon

The jurisdictions in the world where-----

Dr. Conlon will have to finish up.

Dr. Catherine Conlon

-----there is the most holistic model of care around abortion services are the jurisdictions where the rates and incidence of abortion is lowest.

No disrespect to other jurisdictions, but we also have our jurisdiction and our Constitution.

Deputy Durkan, please.

Dr. Catherine Conlon

Yes, but-----

We must be absolutely certain that we abide by that.

Please, Deputy Durkan. Other people want to come in.

Dr. Catherine Conlon

Can I say-----

I know, but I had to wait a long time.

I have been waiting even longer than Deputy Durkan, and other people here who are visitors to the committee want to come in as well.

I will move on.

Dr. Catherine Conlon

I will just say one other thing. When we design legislation, we have no sense of the effect of the measures we implement and the models of care. We only know their effect in terms of access and quality of care when people have gone through those care services and we can research their experiences.

We can improve them.

Dr. Catherine Conlon

We can improve them, and that is what this review is about.

I have a couple of points. At the beginning of her presentation, Dr. Conlon spoke about barriers to care. One of the issues mentioned was how the service is free only to women who have a PPS number. Does Dr. Conlon have any suggestions, or has anything been done since her review, in regard to this? It is an important area concerning women who are isolated, vulnerable or from marginalised groups and so on. What is the ask in that regard?

Ms Marie O'Shea

The report prefers that the service be free of charge to people who are ordinarily resident in Ireland. A definition in the Act of what is meant by "ordinarily resident" might be broad enough to encompass people who are here seeking asylum, or people who are here on a temporary basis such as a student who is here for a year. Better communication to minority groups of the legislation itself, how abortion is governed in Ireland and how to access it would also be of considerable merit.

Dr. Deirdre Duffy

On the suggestion to expand the range of service providers or professionals who can give it, I will draw attention to the comments from service providers who have worked with inclusion services. I refer to health service providers, rather than termination of pregnancy service providers, who have worked in inclusion services and for people in vulnerable populations. Allowing them a point of entry to a health service in order to provide care would assist those marginalised populations. Expanding who can provide care beyond consultants would assist with that.

Dr. Catherine Conlon

The HSE has been innovative. It has taken measures to ensure people seeking care who do not have a PPS number are able to receive that care. The report refers to that. The IFPA is one provider engaging with the HSE to ensure care is made available but it has to take much more elongated steps than it would do for someone ordinarily accessing the service with a PPS number. There are models out there to get it to-----

That is fine. A number of members have commented on the capacity element of it. The report discusses how only 11 of 19 maternity units or hospitals provide full services. That figure has risen by one since 2019. It was expected that four more hospitals would commence providing services. Is there an update in regard to that?

Ms Marie O'Shea

University Hospital Kerry is providing services now. I am not sure whether Kilkenny is at this stage. I do not know the up-to-date status.

One of the difficulties that hospital providers and service users cited was that infrastructural challenges, including the lack of dedicated space, single rooms and theatre access, affect the provision of termination of pregnancy services. Has there been any update in regard to that?

Ms Marie O'Shea

I do not know. I was informed by the director during the preparation of this report that they have put a committee together to look at infrastructural issues.

Okay. The provision of surgical termination of pregnancy depends on resources and requires management support as well as training and education for providers. Again, that engagement with the Department of Health has not occurred, and nor has the implementation. Have there been any structural changes?

Ms Marie O'Shea

I am not aware. Possibly not.

In regard to the challenges in accessing services, the My Options service was commented on at the last meeting and again today. Is Ms O'Shea aware of any increase in publicity around My Options, such as a campaign?

Ms Marie O'Shea

I am not but I believe Dr. Conlon is.

Dr. Catherine Conlon

I had some engagement with that dimension of the service. The HSE has a constant, ongoing mechanism whereby it engages with Google so that if a person googles "abortion information from Ireland" it ensures that the My Options service is the top search return. Our study found that is what most people used in order to access a service. It also addresses the risk of people encountering rogue agencies. With My Options they also have engaged with GPs. One of the concerns has been the number of providing GPs who make their names available to the My Options list. We might have 1,000 GP providers - a portion of them will make their names available to the My Options list when you phone, a portion of them will only make their names available for registered patients at their surgeries, and a portion of them will not make their names available to the My Options list at all. Work is under way to try to create the conditions for more GPs to feel more comfortable about making their names available to the open list on My Options. Some efforts are under way to try to make that a more effective service.

I have two quick questions. Concern was expressed recently that the State has failed to provide a perinatal, clinical, genetics, genomic service. As Dr. Conlon said, the service requires expert guidance to multidisciplinary teams regarding appropriate testing, interpretation of test results and so on. Again, it was mentioned that there is only one consultant in clinical and biochemical genetics with a special interest in perinatal genomics based in the National Maternity Hospital. This was one of the services for which it was expected that funding would be set aside in the budget. This is an area that will possibly fall again. Are there any developments in that area?

Ms Marie O'Shea

I have not heard of any developments. There is a written plan to introduce various genetic services throughout the broader health service, including perinatal medicine, but I have no update on that.

Lastly, there is a need for standardised pathways of continuous care and follow-up care between Irish hospitals and facilities abroad. Are there no changes in relation to that?

Ms Marie O'Shea

I have heard nothing on that. There is a lot of demand for clarity on pathways around section 9 of the Act as well, as highlighted in the report. I do not have any information on that.

I have many other questions but I am conscious that other members wish to come in, particularly non-members. I call Senator Keogan, who has seven minutes.

I might take less and it can be shared among the others. I thank the witnesses for coming in. In March 2022 the HSE acknowledged that remote consultations in respect of home abortions increased the chances of women being coerced into having an abortion. It recognised that meeting the woman in person increases the likelihood of the provider identifying any coercion or domestic abuse. In her report, Ms O’Shea recommended that telemedicine for abortion should be retained as a staple of abortion policy going forward, at least in a blended form. As we know, telemedicine was introduced as a Covid-19 emergency measure and is still in place. I have concerns around telemedicine and how it could be seen as enabling coercion and abuse of women that would go undetected, as well as having a detrimental impact on women who are trafficked in Ireland. This country does not have a good reputation on human trafficking.

Is there an added risk of allowing these vulnerable women to fall through the cracks under the telemedicine regime, even if it is optional? That is my first question.

Second, Ms O'Shea has said a number of times this morning that she felt under pressure to deliver this report. Does she believe that if she had been given more time, or if the review period had been extended from three to five years, it would have helped her to deliver more effective research other than the research she has given on 58 women? Some €11.2 million has been spent per year on abortion services. I ask Ms O'Shea to answer those two questions.

Ms Marie O'Shea

I will answer the second question first, if I can move forward in that way. The pressure I was under in producing this report was due to the fact that I work full time, as the Senator may be aware. It was very much the writing-up of the report which was the pressurising aspect of it. I am quite confident from what I have read, seen and done with regard to the evidence base of this report that if I had spent five years doing this, I would have come up with the same report unless something had dramatically changed in the meantime.

On the remote model of care, I am not aware of the reference the Senator has made to the HSE saying that it has increased the risk of coercive control being exercised on a person's reproductive autonomy. As someone who works in family law, I encounter many people who have been in coercively controlled relationships. As I have said in the report, I believe the remote model of care can work both ways. A person who cannot physically leave the house - who is tracked, trailed and locked in - cannot physically get to a GP. That is a problem. I have spoken to many GPs. As was stated at the START conference, in most cases GPs have adopted a hybrid model of care. They see benefits in seeing the person on one occasion, at least, for public health issues; for example, to see if these persons need to be screened for various sexually transmitted diseases, to talk to them about contraception, to refer them for rhesus D, and to take bloods to see if they are at risk of the rhesus D factor. This is multitudinous but the remote model of care has certainly ameliorated some of the difficulties for people travelling for abortions also.

Can Ms O'Shea see that level of care being open to abuse, as in not being able to actually assess the gestational stage of the pregnancy if there is somebody in domestic abuse, not having face-to-face consultation with the doctor in order to know that the person is suffering domestic abuse, and not being able to see that person's bruises to realise that the person may be coerced into having that abortion? Does Ms O'Shea not feel that is a factor?

Dr. Catherine Conlon

I will join Ms O'Shea in answering here, please. I have a colleague in the school of social work and social policy in Trinity College Dublin, Professor Stephanie Holt, whose expertise is in the area of domestic violence. We have been having some discussions around this. From her analysis of the literature to date, there has not been extensive evidence in the literature or even attention in the literature to this issue. One of the areas of our research direction will be to look at the intersection between domestic violence and reproductive coercion. The model recommended in the report is the hybrid model. It anticipates that the person will attend with the doctor on at least one occasion. That ameliorates the concern the Senator is expressing there.

Is Dr. Conlon aware of the case, about which I read in the Irish Examiner last year, of a young underage girl who was locked in a room and forced to take abortion tablets? Was it put into the report and was it considered by the review?

Dr. Catherine Conlon

There is no clarity as to whether the telemedicine which was used by that person was Irish telemedicine or international telemedicine. One of the problems with making Irish abortion care difficult to access is that there is international extra-jurisdictional access to telemedicine.

Was that case considered by the review?

Ms Marie O'Shea

I considered it. I believe I gave a very balanced approach in the review. I can say, as someone who works with and knows people who have been in coercively controlled relationships, that the remote model of care can work for and against people in those relationships.

It can work for and against them.

Dr. Catherine Conlon

The way one offsets that is with a hybrid model to ensure there is one consultation with the doctor. Can I return to the Senator's reference to the 58 people who were researched in the study? That was as part of the research which I led in the service users strand of the study. That was not-----

Dr. Catherine Conlon

It was not in the same timeframe as Ms O'Shea's work. Our study timeframe was December 2019 to July 2022. That is an extensive and long period of time. We made extensive efforts - I listed the number of sites we went to - to recruit people for the study. We will continue to do research. I will continue to do such research in this area, as I have done since the early 1990s. Continuing to research this area is something where the competency is there and the will is there. We are very open to do that as part of this quality review. We will continuously engage with policymakers with regard to abortion policy.

Ms Marie O'Shea

This also involves public consultation with women.

I thank our guests. I appreciate that others may wish to make contributions also.

I call Deputy Tóibín.

Gabhaim míle buíochas leis an gCathaoirleach agus lenár n-aíonna freisin as teacht isteach anseo inniu. One of the things which probably shocked people from the initial review was that the review made a very significant recommendation that the three-day wait period should be deleted. However, there was an admission that none of the women who have benefited from the three-day wait period were ever spoken to at all. There were shockwaves around Leinster House and among the general public that this was the case.

Section 11 of the report refers to the START doctor group survey, which indicated that approximately 2% of mothers did not proceed to a second abortion meeting or an abortion. At the same time, the HSE was producing figures showing that 16.5% of mothers were not proceeding to a second abortion meeting or an abortion. Would our guests agree that the 2% figure within the report is incorrect?

Ms Marie O'Shea

The research being referred to by the Deputy was conducted by the Irish Family Planning Association. It looked at its data - I believe the number was possibly around the 400 mark, but I stand to be corrected on this - and found that there were 2% who did not return, but as I stated-----

Would Ms O'Shea agree that given the HSE figures, that is incorrect?

Ms Marie O'Shea

First of all, we do not know why they did not return. That is the first issue. We do not know whether they miscarried or went somewhere else. I do not know. One cannot make this presumption. It is a presumption, at best, that they continued the pregnancy as there are no data to support that.

The figure quoted by Ms O'Shea in the report is that 2% of women did not return-----

Ms Marie O'Shea

Yes, and I have set out in the report the potential reasons they did not return. I am unsure if the Deputy saw that.

The HSE figures say that 16.5% of mothers did not return.

Ms Marie O'Shea

The HSE figures - I have checked this with the Department of Health - are based on the claims made by GPs for one visit only. As I have said to this committee on the last occasion and today, there will be a claim for one visit only where the person exceeded nine weeks and six days in pregnancy and would have had to be referred to a hospital. There is also the issue of miscarriage and the potential issue that they did not get on well with the GP and decided to go somewhere else. There are no data on the number of people who continued their pregnancy. We just have figures on the people who attended for one visit only.

I have a short period of speaking time. The 6,728 women who attended the first appointment are women who did not proceed with any abortion, either in a hospital or within the GP's surgery.

Ms Marie O'Shea

We do not have those data.

I will get those data in a parliamentary question for Ms O'Shea. That is the first thing.

Ms Marie O'Shea

Those data are not available.

Dr. Catherine Conlon

May I come in at that point, please?

Allow the guest speakers to respond, please, Deputy.

That is a figure from a parliamentary question.

Dr. Catherine Conlon

Can I respond to Deputy Tóibín? A response to a parliamentary question does not have the rigour of a scientific evidence base when it is being assembled. We have looked at what has informed the answer to the parliamentary question, which is that the Department of Health has detailed to the Deputy the global number of people who attended a GP for one consultation under the Irish abortion service. There are a number of reasons a person attends for one consultation to a GP and then does not return. One reason, as Ms O'Shea has said repeatedly, is that they would go to a hospital.

The first numbers to be removed from that global figure of 6,728 - which is across how many years?

I think it is across the first four years. It is 2019 to 30 June 2023.

Dr. Catherine Conlon

Okay, so the first number to be removed from that figure is everybody who attended a hospital for abortion care in Ireland. We do not know the number of people who attended for the first abortion appointment who had already exceeded 12 weeks. The number of people who continued to travel to Britain from Ireland for an abortion or who accessed abortion outside of the jurisdiction could be removed from that 6,728. Therefore, Deputy Tóibín is making enormous conflations with no scientific basis with that discussion.

Ms Marie O'Shea

Can I-----

I only have two and a half minutes. Very briefly, I want to make the point if I can.

Ms Marie O'Shea

I apologise but it is important-----

I will allow the point to be made and will give the Deputy additional time.

Ms Marie O'Shea

May I just make this point? The Deputy referred to a parliamentary question. I asked the Department of Health what the basis was for its response to that number and it was that it had gone to the HSE and had looked at how many returns had been for one visit only. The Department is not able to aggregate the data as to who continued their pregnancy.

We may have to agree to disagree but the parliamentary question I received referenced one abortion meeting and people who did not proceed with any abortion in this State.

Dr. Catherine Conlon

That parliamentary question has no scientific rigour to its answer.

Please, I am trying to be fair to the member.

Ms Marie O'Shea

It needs clarification.

Even the 2% or 3% of miscarriages which would be expected in that gestational age bracket were to be taken out, and even taking out the number of mothers who go to Britain, or even those mothers who did not make the 12-week mark, there are still thousands of mothers-----

Dr. Catherine Conlon

What about the people who went to hospital? Sorry, the Deputy is being-----

I need a chance to put the question first. Even if that is done, there are still a large number of mothers who would have been able to participate in this discussion. The witnesses said at the start of the meeting, and correct me if I am wrong in this, that an ethicist would not necessarily allow for a person like themselves to speak to mothers who had opted not to have the abortion and to have their child, and that is one of the reasons the review did not proceed to interview one of the women in that cohort.

Ms Marie O'Shea

I gave the Deputy my reasons on the previous occasion why I did not proceed to talk to that particular person. It was because if she could give her side of what had happened, it would be procedurally unfair to not explore then with the medical team who were involved as to what happened. The Deputy raised that issue about the number of incidents raised at the State Claims Agency and I explained on the previous occasion that you could not fairly report on that unless there was some kind of a total review done.

It appears to many people, and not just to, let us say, activists on either side of the debate, that at the heart of this there is a chasm of evidence missing from this discussion. Obviously, the abortion service is used by a significant section of service users, up to 16%, and we can argue back and forth on the percentage, but there are also hundreds of women who have had adverse incidents as a result of experiencing abortions in this country who are suing the State who have never been spoken to either. There are also mothers who had fully healthy children who were aborted under the fatal foetal abnormality element of the legislation who again were never spoken to for the review. It feels that there is an absence of so many people who would have added rich information to the review, and not necessarily from an ideological position. I know mothers who went through with the first abortion meeting and would have loved to have spoken to the witnesses.

Dr. Catherine Conlon

It is essential that I come back in on this because I was the principal investigator, PI, of this research and the Deputy is querying its rigour.

Its methodology.

Dr. Catherine Conlon

Rigour is at the heart of methodology. We had an extensive discussion in Deputy Tóibín's absence with Senator Kyne about this and what the various methodologies and reasons were as to how we could conduct research that would be much more inclusive of all pathways and outcomes to research. There is a model from the early 1990s in a study the Department of Health commissioned, called Women and Crisis Pregnancy, that undertook research with people seeking abortion, people who opted for adoption, and people who continued to parent. I would be more than pleased to be involved in a research study that was that inclusive and that would potentially allow for a sample of methodology that would include the people about whom the Deputy is speaking. However, what we did point out at that point is if we seek to sit down with people, we have to use a scientific sampling methodology. We cannot-----

There are zero mothers in that sample is what I am saying.

Okay, I have to cut the speakers off. Apologies. I call Senator Mullen. I realise we are coming to the end of the meeting and I will try to extend his time as much as possible. It is very unfair to give the Senator two minutes at the end.

Relying on a study from activist groups such as the IFPA or START and using that without in any way prefacing it suggests to me there is not always a consistent concern with appropriate methodologies. However, I am grateful for the opportunity to ask some questions. To be honest, there is a lot that has been said here today and in the report such that you would need an hour. It is the fault of nobody here but it really speaks to the weakness of our parliamentary system that we get at most ten minutes. Obviously, I am grateful to the Cathaoirleach for giving us any time at all as non-members.

I want to start with this issue of the three-day reflection period, and at least the witnesses acknowledged that there are other jurisdictions where a waiting period is actually required.

Ms Marie O'Shea

And it is acknowledged in the report.

Obviously, in this forum there is not time, but it would be helpful if there was a greater willingness to explain the rationale and the logic of that. One thing that surprises me that nobody seems willing to acknowledge when asked this rhetorical question about whether there is any other jurisdiction or area of medicine where there is a required waiting period is that there is an obvious one, and it is euthanasia and assisted dying. I sit on an Oireachtas committee that is currently looking at whether to introduce euthanasia or assisted dying. Even in the most liberal of regimes, part of the so-called safeguards that are discussed in that area is a waiting period. The reason for this is because it involves the termination of a human life. I remind witnesses that in the case of euthanasia, it is a person's decision to terminate their own life, whereas with abortion, we are talking about the termination of another life. I find it strange that there has not even been an acknowledgement by the witnesses to date that there is this obvious example of a similar life and death issue, namely, euthanasia, in various jurisdictions across the world where it is seen as entirely appropriate - not that there would be the possibility of a waiting period but that there would be a mandatory waiting period, and indeed a much longer one than three days. I do not think that really requires an answer. I have not heard it from the witnesses at any stage and it is the most obvious point.

I wish to address the issue of the research. If there are 6,000 people who did not go through with a second appointment, minus X minus Y minus Z for whatever other reasons, such as people going on to hospital or so on, the onus is on the witnesses to establish that there was not a single person who changed their mind as a result of a waiting period, unless they believe that abortion is just completely a matter of autonomy and is never regrettable. The great majority of Irish citizens would believe that, even when those other situations which are possible are factored in, there may well have been several thousand women who changed their mind as a result of that waiting period. As a precautionary principle, the witnesses should be much more attentive to that point. They have never acknowledged it at any stage to my knowledge.

Regarding the proposal that there be a statutory obligation on healthcare workers to refrain from providing misleading information or otherwise engaging in conduct that is designed to, or could reasonably be considered as being designed to, prevent or delay a woman's access to termination of pregnancy, we are all in favour of making sure there is never misinformation, but I find it tendentious and I would like to hear the response of the witnesses as to who they think would adjudicate on what constitutes misinformation. Since there is also a case to be made, and we have seen it over the years where abortion counsellors and medical professionals have often counselled in such a way as to bolster the choice of an abortion and, indeed, to hasten it, I find it strange that the witnesses are only interested in prohibiting through statue conduct that would be designed to prevent or delay a woman's access. I see a lack of neutrality in that and I ask the witnesses to address that point briefly as I have another question.

Ms Marie O'Shea

I will address those questions in the reverse. When the Senator says the statute does not address people who are somehow encouraging people to have abortions, the criminalisation section of the statute is sufficiently broad enough to address that.

In terms of the provision of misleading information, when somebody is provided with a scan at a centre that is holding itself out to be pro-abortion and is told unequivocally that they are earlier in the pregnancy than they are when the scan is looked at or when they have a second subsequent scan somewhere else, that is quite a clear-cut case where a person has provided misleading information, has delayed care and has tried to interfere with somebody's reproductive autonomy.

I acknowledge in the report as regards the three-day wait what the policy of the Legislature was, which was so that people did not make a decision in haste and later regret it. What is being proposed in the report is not taking away from anybody the right to have that reflection period. In a world where I think we can accept that women have the capacity to make decisions, to weigh up the evidence and to say, "I am not quite sure today. I would like to take the opportunity to come back on the next occasion", there is no threat to persons who have had the experience the Senator mentions, who decided against having a termination of pregnancy and who decided they would continue with the pregnancy. There would be enough safeguards in there to protect those people.

Nobody has any idea whatsoever of how many numbers are involved. The Senator referred to the data that we relied on that came out of the IFPA and START, they are publications that are all in peer-reviewed journals. You do not get into peer-reviewed journals without the methodology being rigorously applied. Those peer-reviewed articles have to be reviewed by several academics to make sure they are rigorous and that they are able to go into those journals, because those journals have their own reputations to uphold.

If I may, it strikes me that you are only really-----

Dr. Catherine Conlon

Excuse me, I did want to respond as well.

We are late on time.

Dr. Catherine Conlon

If we are being asked questions, we need to have fairness in our capacity to respond. What we are proposing here is a model of care where a person can attend to consult a professional doctor to discuss their stance on their pregnancy, with one option being termination but other options obviously being available in the Irish health service. We are not saying the person must decide "Yes" or "No" at that one consultation. We are saying that person should at least have the option to come back once with as long a period between the first consultation and the second consultation as is possible. I argue we are taking a stance here that states the decision to have an abortion is one that should be carefully supported by a health service with at least two fully funded consultations. The architecture around that is a very well-developed pregnancy counselling service that I trust as a professional service that counsels women and is person-led, which all of the counselling services, which I have looked at in detail, are. I trust our healthcare professionals, counsellors and doctors. I trust women to make decisions. I would prefer a model of care that allows women to come back at least twice before they make a decision. My position is that the review seeks a model of care that supports sound decision-making for women and an accessible service. That is the way we can reduce the instance of abortions that are not in the best interests of people.

Okay. Apologies, Senator Mullen. I cannot let you back in. Deputy Crowe is looking to get in and-----

That was a very ideological response. I think I have to put that on the record and-----

Apologies. There was not-----

-----we need something much more objective.

Apologies. There was not enough time to take everyone. Deputy Crowe has arrived-----

For the record, you have allowed one member to speak six minutes over their time. I had a meeting across the city and I am after pedalling over here. If it is ending at 12.30 p.m., then it is ending at 12.30 p.m., but if it goes over time for one member, then I should be allowed to contribute a single question at the end of it.

Chair, some of us have been here for three hours, including Senator Mullen.

If you want to shut down debate, that is fine.

I am not. Hold on.

I would accept it if-----

The Deputy can criticise-----

He cannot come in at the end of it.

Take it up with me afterwards.

To finish my point, if the meeting ends at 12.30 p.m., that rule would hold water, but it does not.

If you had been here at 9.30 a.m.-----

-----you would have had plenty of time to come in.

It does not when you allow it to run over for one member.

Can I proceed to ask my question?

-----apologies that we are ending on a negative note.

In fairness, Deputy Crowe is a member of the committee and we were all double-booked. I think he should be allowed in with just one question.

I am ending the meeting.

I thank Ms O'Shea, Dr. Conlon and Dr. Duffy for their time in attending today's meeting and assisting the committee in this matter. The committee will be discussing this and will decide on the next steps in relation to this issue at our private meeting, which will be next week. I want to say that I am concerned that there has been no follow-up from the Department and the implementation group in relation to the witnesses' work. Maybe we as a committee can possibly follow up with the relevant Departments in relation to that. Apologies again to those who did not get in today and those who did not have enough time today-----

No need to apologise, Chair.

-----and I will end the meeting. The meeting is now adjourned.

The joint committee adjourned at 12.36 p.m. until 10 a.m. on Tuesday, 24 October 2023.
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