Ms Janice Donlon:

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

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

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

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

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

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

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

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

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

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

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

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

It is recognised by us and the services that in the 20 years since the commencement of the Regulation of Information (Services Outside the State For Termination of Pregnancies) Act,1995 there have been many developments in technology, including access to the Internet. Many women are now bypassing crisis pregnancy counselling services and accessing information on abortion services directly from the Internet. While the numbers attending services are decreasing, counselling services report that those attending services are presenting with more complex and multiple issues. The challenge for the programme and the counselling services is to ensure that women in most need of crisis pregnancy services and supports feel that the services are relevant to them and will meet their needs.

Many of the counselling services funded by the programme also support women and their partners through the diagnosis of a fatal foetal abnormality or life limiting condition. Additional training and support has been provided to these services to ensure they are able to respond to the needs of this client group. Counselling services have forged links with maternity units and have the expertise and the capacity to support women and their partners through this difficult time.

I shall now turn to the issue of crisis pregnancy agencies, which are not funded by the State. Some organisations that advertise as crisis pregnancy counselling services have a hidden agenda. The service they provide is designed to influence the choice a woman makes and to pressure a woman into doing something she may not want to do. Once these agencies have been contacted by a client they can seek to delay the counselling process and, in certain cases, show clients inappropriate images or use other tactics in an effort to influence their decision. These organisations are not State funded and women are advised to find out as much information as possible about a pregnancy service before they make an appointment. All HSE sexual health and crisis pregnancy programme funded services are advertised on positiveoptions.ieand will provide non-directive, non-judgmental counselling.

Post-abortion services that are available include post-abortion counselling provided by the same funded services which provide crisis pregnancy counselling,. Details of these post-abortion counselling providers are available on abortionaftercare.ie.

Information on the availability of free post-abortion counselling in Ireland is also provided by abortion clinics in the UK and the Netherlands. The programme links with abortion providers to ensure the information is made available to women who have travelled from Ireland. Post-abortion psychological support allows a woman a safe space in which to explore and articulate her feelings, whatever they may be, towards the decision made and perhaps the experience of the abortion itself. A client may require a number of counselling sessions post abortion and the counsellor is available to support the woman depending on her individual needs. A woman may attend for post-abortion counselling shortly after her abortion or she may attend at a later stage if issues emerge related to other life events. The number of women who access post-abortion counselling has remained steady over the last number of years and in 2016 a total of 1,377 clients were seen for post-abortion counselling.

A post-abortion medical check-up is also available for women to ensure they have fully recovered from their procedure. A post-abortion check-up normally involves a blood pressure check and an examination of the woman's abdomen. The doctor will confirm that the pregnancy has ended, check that bleeding pattern is normal and there is no infection and will assist the client with their contraceptive needs.

A number of the services funded to provide crisis pregnancy and post-abortion counselling services also provide free post-abortion medical check-ups. The details of these services are available on abortionaftercare.ie. Attendance at the medical checkup also allows an opportunity for the doctor to refer the women to post-abortion counselling if such a referral appears beneficial. The numbers attending these services is low; in 2016, a total of 442 women attended medical check-ups funded by the programme. Women may attend their GP on their return if required or, depending on the type of procedure they have undergone, may not require a post-abortion medical check-up, for example with early medical abortion.

I shall now address some behavioural trends and the research relating to crisis pregnancy, including use of the abortion pill. As a core function of its work, the programme monitors behavioural trends relating to its mandates, using a range of tools and indicators including general population surveys and statistics. Research informs us that crisis pregnancies happen to women and their partners from all different ages, socio-economic backgrounds and with different relationship statuses. The majority are married, engaged or in steady relationships when the crisis pregnancy occurs. The most common reasons the pregnancy is seen as a crisis is because it was not planned or the woman and her partner consider themselves too young. The average age at which a crisis pregnancy occurs is stable at 24 years for women and 25 years for men.

When we consider the outcomes of crisis pregnancy we can see that parenting is by far the most common outcome for those who experience a crisis pregnancy. A survey of the general population found that when asked about their most recent crisis pregnancy 73% of women reported that they chose to parent. In the same general population survey, 2% of those asked about their most recent crisis pregnancy reported that they chose adoption. Traditionally in Ireland adoption was a common response for women experiencing a crisis pregnancy; however, the number of women placing their babies for adoption has decreased significantly in recent decades. A figure of 24% of women in the same general population survey who reported experience of a crisis pregnancy reported that they chose to have an abortion following their most recent crisis pregnancy.

With regard to abortions in other jurisdictions it is well documented that many women travel from Ireland to other countries to access legal abortion services. The programme analyses data collated by the Department of Health in the UK and the Ministry of Health in the Netherlands on the number of women travelling to those countries from Ireland for an abortion on an annual basis. In the majority of cases, women travelling from Ireland for an abortion travel to England. In 2016, a total of 3,265 women gave Irish addresses at UK abortion services, representing a rate of 3.2 per 1,000 women. There has been a gradual decline in the number of women availing of abortion services in the UK since 2001. In that year there were 6,673 abortions to women from Ireland in UK abortion clinics, representing a rate of 7.5 per 1,000 women. The Ministry of Health in the Netherlands has collated data on women providing Irish addresses in Dutch abortion clinics since 2010. Prior to 2010, the programme linked directly with the main abortion service providers in the Netherlands to establish the number of women providing Irish addresses there. In 2015, 34 women were recorded to have provided Irish addresses in abortion clinics in the Netherlands. These figures have significantly declined since their peak in 2006 when the number was 461. The Netherlands has emerged as the only other jurisdiction to which women from Ireland have been travelling for abortion procedures in any significant numbers.

I shall now turn to the numbers of abortions in Ireland under the Protection of Life During Pregnancy Act 2013. The Act defines the circumstances within which abortion in Ireland can be legally performed. The total number of abortions carried out in accordance with this Act in 2016 was 25. There were 26 in each of the years 2014 and 2015, with 2014 being the first year in which data was reported.

On the issue of abortion pills, they are designed to induce an abortion for a woman who is less than nine weeks pregnant. Abortion pills are used by abortion providers in medically supervised clinics in countries where abortion is legal. These are referred to as medical abortions. The programme is aware that some women are accessing abortion pills in Ireland from international online providers. In order to try to understand the incidence of this, the programme set up a reporting relationship with the Health Products Regulatory Authority in relation to the number of abortion pills seized by customs officers annually. The programme has provided training and support to all funded services on this emerging issue. All services have developed protocols in this area and training manuals and online resources have been updated with relevant information.

The reasons women may be accessing abortion pills online are cost and access. For women who have made the decision to terminate a pregnancy, the cost associated with travelling from Ireland to another country for a medically supervised termination is high. Research finds that higher earning women are more likely to travel to other countries for abortions over their lower earning counterparts. Until recently it was difficult to make an assessment of the level to which this practice is occurring as limited information was available. Recently published research suggests that more women are contacting online providers of abortion pills annually and becoming more aware about the availability of these drugs online. As the committee has been informed by a previous witness Dr. Abigail Aiken, her study found that over the period January 2010 to December 2016 the number of women from Ireland who contacted an online provider of abortion pills tripled. In 2010 there were 548 online consultations completed by women from the island of Ireland. In 2016, the number had increased to 1,748.

Another research article, published by the same authors in 2017, reports on the experiences of women following taking the abortion pill in Ireland. The study reports on 1,000 women who underwent self-sourced medical abortion from the online service. The study reports that while the vast majority of women did not need to contact medical services following taking the abortion pill at home, approximately one in ten - 9.3% - reported to the online provider that they were experiencing a symptom for which they were advised to seek medical advice and the vast majority of these women sought medical advice as advised.

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

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

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