I thank the Chairman and members of her committee for the invitation to address them today.
I am a medical doctor and have specialised in reproductive health for over 20 years. I am registered with the Irish College of General Practitioners as a contraceptive tutor and a tutor in the provision of long-acting reversible contraception. I am a member of the European Society of Contraception and Reproductive Health and the Irish Association of Sexual and Reproductive Healthcare Providers.
I have been the medical director of the Irish Family Planning Association since 2008. The IFPA is Ireland's leading sexual health charity. It promotes the right of all people to sexual and reproductive health information and dedicated, confidential and affordable health care. We operate two not-for-profit medical clinics where we deliver services, including contraception, post-abortion medical check-ups, cervical screenings, and screenings for sexually transmitted infections. We also have ten centres nationwide where we provide free pregnancy counselling and post-abortion counselling services.
My colleagues and I work in the context of an extremely restrictive legal framework, principally, the eighth amendment of the Constitution. We are also bound by two pieces of legislation that include criminal sanctions, the Protection of Life During Pregnancy Act and the Abortion Information Act. Navigating these complex legal barriers while trying to maintain a caring clinical relationship is an immense challenge for us as health care providers.
This presentation will address the socio-economic dimensions of crisis pregnancy, and the impacts of current Irish law on women who experience an unintended pregnancy or a pregnancy that has become a crisis for other reasons. I have included case vignettes in appendix one to this submission to further illustrate women's decision-making. I am happy to expand on issues raised in these afterwards.
An unintended pregnancy is a frequent occurrence among women of reproductive age. While for some women this is a joyful and welcome situation, for many it is a traumatic and devastating life event. Conversely, a wanted or planned pregnancy can become a crisis. An unintended pregnancy can mean the difference between a woman determining her own future or seeing her plans derailed and her aspirations frustrated.
In 2016, more than 3,000 women and girls gave Irish addresses at UK abortion clinics. These women were from all walks of life and from every county in Ireland. In addition, as Dr. Abigail Aiken explained in an earlier session, women are increasingly accessing the abortion pill online.
Clients of IFPA doctors and pregnancy counsellors include women who have made a decision to have an abortion for a wide range of reasons related to their physical and mental health and well-being, and their ability to cope with a pregnancy. The majority of our clients who consider abortion do so because to continue an unintended pregnancy would be an intolerable burden at this time in their life. Any meaningful change from the current legal situation must include these women.
Each woman weighs up her particular circumstances very carefully before deciding that she is unable to cope with a pregnancy. The factors a woman considers include the following: her family situation; her income; her social support networks; her plans for education; her working conditions; and her social and physical environments in terms of housing, relationships and so on. Many women in this situation already have children. They know what it means to be a mother. For them, the need to care for their children is the primary reason that they decide not to continue with another pregnancy. A woman may be trapped in an abusive relationship, or fear that continuing the pregnancy will trap her and her children into a lifelong relationship with an abuser.
Pregnancy counselling services, such as the IFPA, can support women through their decision-making and give them information about abortion services. Increasingly, our clients are women who experience multiple forms of disadvantage which, in turn, restrict access to abortion. Indeed, the term "socio-economic" masks the reality that an unintended pregnancy can have devastating impacts on a woman's life and that of her family.
Once a woman in Ireland has made the decision to have an abortion, she is faced with a range of further obstacles and difficulties. Cost will be a significant factor in the decision of almost every woman. She will need to consider the practical supports available to her and ask herself the following questions. Can she organise child care? Can she get a sick certificate from her doctor? Can her partner get time off to accompany her? As a migrant woman, is she legally able to leave the country? Will she be able to navigate the immigration procedures? If she has a disability, how will this impact on her ability to access care? Not everyone lives in Dublin or Cork. Women who live at a distance from the major cities, particularly if they are dependent on public transport, may have a very lengthy journey to an airport if they decide to travel to the UK for a safe and legal abortion. Clearly, this constitutes a further significant barrier. For minors, all of these matters are immensely more complicated.
Non-judgmental, non-directive counselling by a trained professional can be a huge support to a woman at this time, but it is no substitute for access to services. We cannot ignore the fact that socio-economic factors frequently determine whether a woman travels for a legal abortion or resigns herself to the reality that her only option is an illegal abortion. For some women, the obstacles are insurmountable and they are forced to continue the pregnancy against their wishes.
When abortion is criminalised, as it is in Ireland, the burden of accessing care falls on the woman rather than the health care system. This is because, whether a woman travels abroad for legal services or has an illegal abortion in Ireland, she must leave the mainstream health care service. Her experience will not meet international health care standards such as those of the World Health Organization and the Royal College of Obstetricians and Gynaecologists.
If a woman decides to travel for abortion, the information Act prohibits her doctor from making a referral to services in another State, even if she does not speak English, has a poor educational level or has an underlying medical condition. Unlike any other medical treatment situation, the continuum of care is broken. The onus shifts to the patient to make contact with a doctor outside of Ireland and to provide her medical history. She must make her way to a private medical facility in another country without the supports that apply in other situations where people travel for health care.
A woman who is unable to travel, or for other reasons opts for an illegal abortion, is faced with the challenge of trying to find a reliable online provider without medical assistance. She also risks prosecution under the Protection of Life During Pregnancy Act if she self-induces abortion, as does anyone who assists her. In either scenario, an underlying medical condition that is easily managed in the context of legal abortion may become more risky.
Yet another way in which care falls below acceptable standards is a lack of contraceptive provision. As Professor Arulkumaran told this committee, best practice in the context of where abortion is legal is that contraception is offered as part of integrated abortion care at the initial presentation and the post-abortion consultation. For women in Ireland, this is not the case. This may be because her first presentation is not with a doctor, and so she does not have immediate access to contraceptive information. Online abortion pill providers are not in a position to provide ongoing contraception. I frequently see women who, having paid all of the costs of going to a private clinic for an abortion, for example, perhaps €600 for an abortion at ten weeks plus the cost of her travel, cannot afford to pay for post-abortion contraception, particularly their preferred method of a long-acting reversible method of contraception, which are the most effective.
All of these failures of care are related to the disruption and fragmentation of care in the context of restrictive criminal abortion laws. We see this also in relation to post-abortion care. Women who can access abortion in their own country have a clear post-abortion care pathway with the same provider. In the event of complications, there are robust and timely pathways for referral, as recommended by the Royal College of Obstetricians and Gynaecologists, RCOG. This is not the case for women who travel from Ireland. While free post-abortion care is funded by the HSE, and available to women from providers such as the IFPA, our experience is that only a small number of women avail of it.
Women who access illegal abortions receive a still lower standard of care. In addition to the fragmented care pathway, they risk inadvertently accessing medication from an unreliable online source which could be inactive, inadequate or potentially harmful. In my clinical experience, women accessing medication online tend to report problems late. Fear of prosecution is a real deterrent to accessing health care for some of these women.
A substantial number of women are accessing abortion in this way. As Dr. Aiken made clear, most women experience relief at the availability of this option, but that is not to say that it is acceptable health care. It is an unregulated and unsafe practice, the harms of which are not being reviewed or measured by any public body. No one is being held accountable for this, and the Government cannot continue to ignore it.
In considering the real health concerns associated with the criminalisation of abortion, we must not forget the impact of stigma on women. Research by the American Psychological Association has found that feelings of stigma, perceived need for secrecy, exposure to anti-abortion picketing and low perceived or anticipated social support for the abortion decision negatively impact women’s post-abortion psychological experiences. Every day, IFPA counsellors hear from women about these experiences. Women’s privacy and informed consent are invaded in ways that do not happen when services are locally available. Some women must make multiple disclosures of a private and personal health situation to, for example, community welfare officers, officials in the Department of Justice and Equality, staff in direct provision centres and social workers. Decisions made at this level can turn obstacles into barriers. Women’s dignity is violated at every step. Their right to confidentiality is taken from them so many times, right up to the moment when they find themselves in taxis from airports to abortion clinics with women they do not know.
In conclusion, our legal system imposes a significant burden on women at a time of crisis and stress in their lives. It criminalises women and health care providers. All women are disadvantaged and discriminated against when they are forced to travel to another state to access abortion services, and even more so if they access illegal abortion. The requirement to travel for abortion forces a reduced quality of care on women. Again, this is even more the case with illegal abortion. We have an urgent need for safe and legal abortion care in this country. This means equitable access, regardless of socio-economic status, to high quality, affordable, local services in Ireland that respect women’s autonomy and decision making. As a society, we must take responsibility for ensuring that this becomes a reality in law and in health care practice.
I thank the committee and I am happy to answer questions.