Ms Orla O'Connor:

I thank the committee for inviting the National Women's Council to present to it today. We appreciate the opportunity. As the committee knows, the National Women's Council is the leading national women's membership organisation, with more than 190 members. We also convene and chair the Abortion Working Group, a collective of more than 20 civil society organisations and healthcare providers, which was established in 2019. We collectively submitted to the abortion review as we believe that significant legal changes and practice improvements are required if the health Act is to guarantee equitable, accessible and legal abortion for all women and pregnant people who need it.

We want to take this opportunity to recognise and acknowledge the significant positive change the introduction of abortion in Ireland has brought to women's reproductive rights and to women's lives. We are at a critical moment now where we can fully realise the overwhelming vote of the Irish public to enable access for all women who need abortions. As time is limited, I will focus on three key challenges that we believe must be addressed. The first is the restrictive legal framework. The second is the national coverage, and the third relates to data collection.

In terms of the restrictive legal framework, instead of creating an enabling legal framework, the law acts as a gatekeeper creating a series of obstacles that prevent access to abortion, disproportionately affecting the most marginalised. The World Health Organization's 2022 guidance recommends against laws that prohibit abortion based on gestational age limits and is clear that gestational age limits are not evidence-based. Legal limits are contrary to the ideal model of patient-centred care whereby medical needs are met in line with clinical best practice and patient preferences. Our strict 12-week window, which is actually just ten weeks from conception, is particularly challenging if you have irregular periods or need to undergo an ultrasound scan, and then in addition there is the mandatory three-day wait. As with all rigid frameworks, it is women who are the most vulnerable who are impacted the most. For example, adolescents, disabled women and pregnant people and women in situations of domestic violence who may not have freedom to leave the house.

In addition, the 28-day mortality clause for fatal foetal anomalies is also very problematic. This clause means doctors are unable to provide abortion care in cases where the life expectancy for the foetus after birth is short, but may not be as short as 28 days. This has caused significant challenges for doctors in determining eligibility, as well as huge heartbreak for women and families. We are particularly concerned that the proportion of Irish residents travelling to the UK on these grounds has significantly increased, accounting for a third of all those who had to travel in 2020. Analysis of the data suggests that the 28-day clause has created a two-tier system whereby for every three women deemed eligible for care here, two are forced to travel to the UK. We must be clear that rigid gestational limits, mandatory waiting periods and narrow foetal mortality clauses, all serve to impede the ability of doctors to provide urgent care when required, while also placing additional stress on women and pregnant people during a challenging and stressful time.

Furthermore, under the terms of the Act, a doctor who provides abortion outside the specific circumstances laid out in the law may face a prison sentence of up to 14 years.

This means health professionals, under the threat of prosecution and criminalisation, are essentially forced to police themselves, determining when and whether the statutory criteria for access to care have been met. That is why we are recommending that abortion be available on request up to viability to ensure that no woman or pregnant person is forced to travel abroad for essential reproductive healthcare. We recommend the removal of the three-day wait period and the full decriminalisation of abortion care in line with the WHO guidance.

I will now turn to the national coverage. At present, just one in ten general practitioners, GPs, are providing abortion services in Ireland and, concerningly, the pool of GPs registered with My Options who provide care to the general public is even fewer than this at just 7% of the overall GP population. Data shared with the National Women's Council by the HSE in March 2022 show that half of counties have fewer than ten GPs offering the service currently; in some counties it could be as low as one GP per county as the data were provided in a zero to ten range rather than the total number. Indeed, only four out of 26 counties have a well-developed community network of providers - Dublin, Cork, Galway and Wicklow. Although abortion providers are very committed, limited coverage is therefore a significant barrier to access. The reality of poor nationwide coverage coupled with the two-appointment requirement is a heightened burden on women and pregnant people, particularly the disabled community.

GPs have highlighted the threat of anti-abortion activities as one of the biggest impediments to new providers coming on board. As such, it is difficult to disentangle the urgent need for safe access zones legislation from the issue of poor geographical coverage. We are recommending that to address regional barriers to access, there must be focused efforts to improve community and hospital coverage. Adequate early abortion care should be understood as a core part of our primary care services. If it needs additional resources from the HSE, they should be provided as required. Maternity hospitals must also be mandated to provide the service in line with the law. Where necessary, new medical appointments should be fast-tracked to address any gaps in service provision and the necessary resources should be made available to address the infrastructure challenges. Safe access zones legislation must be introduced to give healthcare staff assurance that in stepping up to provide this vital service they will be protected from harassment and intimidation.

Turning to the issue of data collection, we are concerned that the very low number of providers in community and hospital settings is reflective of silent refusal to provide abortion care, which is not being monitored or recorded appropriately and which is impacting on the effective operation of the Act. Ensuring that conscience-based refusal of care does not hinder access to essential reproductive health services requires a clear, legal and policy framework and this must be urgently developed. Medical providers should be obliged to record refusals of care on the grounds of conscience and detail the service to which they referred the woman or pregnant person. We believe enhanced data collection is key for mitigating risks and barriers to service users. As the Institute of Obstetricians and Gynaecologists in Ireland stated, abortion is "a time-sensitive service for which a delay of several weeks, or in some cases days, may increase the risks or potentially make it completely inaccessible. The consequences of being unable to obtain an abortion profoundly impact a person’s life, health, and well-being.” We recommend expanding the current publicly available abortion data set to include wait times, recording of refusal of care and referral onwards. Conscience-based refusals to provide care should be monitored by the Irish Medical Council to ensure compliance, and failures to adhere to guidelines regarding swift referrals should lead to sanctions.

The repeal campaign that led to the landslide "Yes" victory for removal of the eighth amendment from the Constitution was one of the most important social movements in our history for Irish women. The message was clear - all women should be able to access healthcare at home with their doctors and make decisions regarding their care needs. That is why we believe the review of the legislation is such a critical moment to deliver on the referendum and to deliver to women the reproductive rights they need.