Oireachtas Joint and Select Committees
Wednesday, 15 November 2017
Joint Oireachtas Committee on the Eighth Amendment of the Constitution
Socioeconomic Context: Dr. Caitriona Henchion and Mr. Niall Behan, Irish Family Planning Association
Dr. Caitriona Henchion:
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.
I thank the witness for her presentation. I will start with two questions. The witness mentioned the importance of non-directive counselling. Does she or her counsellors have any experience with women who may have initially accessed counselling services from a rogue agency? How often would that happen and what impact does it have on trying to manage their pregnancy?
My second question is on the connection between socio-economic status and mental health. In her experience, does she find that women who had good mental health previously are faced with mental health issues in pregnancy because of their socio-economic status and not being able to manage their pregnancy in the manner in which they might choose?
Dr. Caitriona Henchion:
With regard to the question on rogue agencies, the counsellors certainly encounter women from time to time who made initial contact with an agency that has an agenda to deter women from seeking abortions. The usual issue that arises is that the woman will have been delayed. There will have been several appointments and she will have been delayed in seeking care. Obviously, we do not know if some women are deterred completely because if that is the case, we will not see them. However, the counsellors see women who have had negative experiences in such agencies.
In terms of the socio-economic effects on mental health, particularly in respect of pregnancy, socio-economic factors and mental health are very much intertwined in every aspect of life. Sometimes the socio-economic burden of an unintended pregnancy can have a negative effect on somebody's mental health. It becomes very difficult to separate those issues because in most such cases, many different issues are present. Obviously, if somebody is concerned about, perhaps, an abusive partner, this becomes much more likely and it is more likely that her mental health will suffer if she is in a pregnancy she feels she cannot manage. The two issues are very much intertwined.
With regard to some of the examples the witness provided to the committee in the appendix, she spoke about the Protection of Life During Pregnancy Act and some of the difficulties that has presented. Perhaps she will expand on that.
Dr. Caitriona Henchion:
The issue doctors or counsellors have with the Protection of Life During Pregnancy Act is, first, the procedural difficulties involved in the Act and, second, the uncertainty. If somebody presents and one feels there is a possibility she might qualify for an abortion under the Act, one cannot have any certainty about that. One can only say to her that there is a possibility that she might be considered for an abortion under the Act. One can explain the procedures, which are that she will have to be seen first by an obstetrician and then either by another obstetrician or another physician or two psychiatrists for a decision to be reached. If somebody is suffering from mental ill health, for example, it is quite likely she will be attending a psychiatrist already. She might have already disclosed that and she has now disclosed her situation to a counsellor or a doctor. The prospect of having to go through three more similar investigations with another medical person is off-putting for her. Our experience, and it is not huge because not many women will qualify under the Act anyway, is that where these issues arise, the woman will choose to travel if she has the means. She does not want to have the uncertainty and the rigour of having to go through the Act.
If we use all our time here, so be it. The presentation was absolutely excellent. I was struck by Dr. Henchion's comment that unintended pregnancy is a frequent occurrence. This committee has spent a great deal of time considering circumstances of rape, fatal foetal abnormality and the woman's health. In the experience of the IFPA, the majority of women who decide to access abortion would not fit into those categories. Perhaps she will expand on that and, by implication, what that means for this committee. We have been looking at reasons but, in fact, the real circumstances of women accessing abortion fall outside of those reasons. What does Dr. Henchion think is the best way for us to deal with the task we have been given?
Dr. Caitriona Henchion:
To give a little background, other presenters to the committee have explained that a very small number of abortions are sought on the grounds of either foetal anomalies or rape. The vast majority of them are far more complex and involve many socio-economic factors. As to what those factors are, there are as many different sets of circumstances as there are women. Various combinations of factors occur. It might be a young woman who is still in education or very early on a career path who does not have the support of a partner and who feels she will damage her future by continuing with the pregnancy. It might be an older woman who has children and has just got back into the workplace. As in the first vignette I gave, there might be financial difficulties for that family that they are trying to get through and they feel another pregnancy would stop them being able to get their lives back on track.
We have some women with very severe forms of disadvantage. For example, some women are battling addiction and might have children in care. They are on a pathway out of addiction and have accessed services. They have succeeded in keeping sober. They just feel that the mental health toll of a pregnancy and the fact of having another baby might put their goal of getting their plans back on track out of their reach. There are a vast number of different situations that occur. Trying to set out a list of conditions that would fulfil a socio-economic criteria is unrealistic. The only way to deal with that is to have some sort of open access so that these conditions can be met. Whether the committee decides to put gestational limits in place for that is a matter for the Government. To ask women to meet certain criteria does not recognise the complexity of the issue in the first place.
Two things are apparent to me but I do not want to put words in the mouth of Dr. Henchion. In essence, she has said that we would not meet the needs of the majority of women who need to access an abortion if we opted for a restrictive reasons-based criteria. I do not know how one would define a socio-economic reason. In that sense, and by comparison with other jurisdictions, what is the best way to do that? Is it early availability without restriction? Has the IFPA studied examples in other States?
Dr. Caitriona Henchion:
Portugal was very similar to us in so far as it had very restrictive laws around abortion. However, Portugal introduced unrestricted access up to ten weeks gestation and there are more restrictions in place for later gestations. That was done to address the fact that women can access abortion without having to prove or make a case up to that time.
I shall digress for a minute. The World Health Organization has been incredibly strong; it has said one cannot talk about abortion without talking about contraception. Dr. Abigail Aiken mentioned that 44% of the women who accessed the services of her organisation, Women on Web, had not used contraception. There is a huge link between the availability of contraception and unintended pregnancies, which is the real issue. What measures should we put forward in that case? This committee will deal with ancillary recommendations.
Dr. Caitriona Henchion:
There are two key issues when it comes to barriers to contraception although there are many lesser ones too. When I am at work in my clinic I provide contraception for a good part of my day, which is fine. I can only see the people who make it in to see me. That means the women must know that a contraceptive service is available, be able to afford contraception services and know where to access them. First, one needs good quality education and awareness programmes so that women are aware of contraceptive methods and where to access them.
Second, one must remove the financial barrier. Without question there is a financial barrier. A person with a medical card can access services for free. However, a person on the cusp of not having a medical card who is not well off cannot access services. I have seen what happens when women seek long-acting reversible contraceptive methods, such as the Mirena coil or whatever. They are really interested and want it because they want to be very safe. Quite often, when I outline the cost to them they defer their decision. Unfortunately, some of those women end up using much less safe methods. They may have already said that they were on the pill before but could never remember to take it yet I must send them out with a prescription for the pill knowing that it is not going to be the best method for them because they cannot afford to get what they want.
Criminalisation has come up a fair bit. It is a fact that most people do not want to see women or health care providers criminalised. Is the threat of criminalisation a prevailing issue for IFPA staff? What would decriminalisation mean for the delivery of IFPA services?
Dr. Caitriona Henchion:
Without question the criminal sanctions in the law have a chilling effect. To be perfectly honest, I cannot see why anybody inserted a 14-year prison sentence unless one wanted it to have a chilling effect. That seems obvious. As a group, doctors are very anxious about anything that would damage their reputation in any way. Being associated with potential criminal charges, even if one is not sent to prison, is a huge threat and definitely influences people in the way they manage consultations. It means that instead of a doctor being comfortable and free in his or her discussion with somebody one is continually, in one's mind, trying to be guarded and careful about anything one might say that could possibly be interpreted as not being in keeping with the law. Decriminalisation would take away that layer yet one still can have lots of ethical and clinical guidelines. The Medical Council is still in a position to sanction doctors who have been found to have behaved inappropriately. It should not mean that people think doctors will somehow behave badly if there is no criminal sanction. Decriminalisation will allow doctors to have a freer conversation with the woman in that position.
A lack of access is a very real and living thing. In terms of the consultation, Dr. Henchion has clearly pointed out the issues of affordability and availability of services nationally. She has also pointed out that one cannot define socio-economic reasons as life happens and a whole number of things take place, and one must trust somebody to make the best decisions for themselves.
In the context of the provision of services, recently the head of the Royal College of Obstetricians and Gynaecologists in Britain proposed that nursing staff, midwives and so on should be able to dispense the abortion pill, and it should be made widely available in the early stages of pregnancy without much hoo-hah. It could also be dispensed through pharmacies or in the normal regulatory way in which we deal with any sort of pharmaceutical tablets or whatever. Does Dr. Henchion believe the abortion pill should be affordable and made available nationally through our network of pharmacies, local nursing services or local GPs? Perhaps I have not explained myself. Would that be a good way of opening services up from an access point of view?
Dr. Caitriona Henchion:
Medical abortion, as a method, certainly has the ability to do what the Deputy has said but one would need a lot of expert advice on how to set up the service. A certain amount of things would need to be in place. Perhaps, pharmacies might not turn out to be the best place to provide the service. We would generally feel that proper gestational assessment beforehand is an important part of providing abortion care, which might be difficult in the context of pharmacies. A primary care based service is possible but, most important, one would need to have robust and timely referral pathways. Overall, abortion is a very safe procedure and very few people will need further interventions. One needs to have the service set up so that interventions are not delayed when needed.
That is helpful. Dr. Henchion made a strong point about the fact that the burden of access care falls on the woman rather than on the health care provider. Is there a comparative scenario in terms of health care provision?
Such interference can steal one's thunder. Before I ask questions and everything else, I want to say the following and have it minuted. I feel that it is regrettable that we have not heard from people or representative groups who have experienced crisis pregnancies but chose not to have an abortion and parent instead.
Several pro-life groups who have been invited to appear before the committee have not shown up, and there is still a vacuum. Chairman, I wonder if the pro life spaces will be filled.
We are expecting that a group suggested by Deputy Mattie McGrath will come. We assume they will come. We had to rearrange their slot because of the week off. It so happened that we had TMFR in the week before. The intention was to have the group in the week after, which was last week, but we are in their hands as to whether they want to come in. My understanding is that they are due in and there is no question of them having said that they do not want to come in. I hope they will come in because we really want them to come.
That is where I am coming from. In fairness, for balance and for the audience who view the proceedings, I have said all along that I have been very open minded. I want to hear every side of the story. I have a particular viewpoint, but that does not mean to say that I do not want to hear every single presentation. I appeal to anybody who has been invited to appear before the committee, to take up the offer to come before the committee and to let us do our job.
It is very helpful that Deputy Rabbitte says that, because I am blue in the face trying to get people to see that this is an environment where we want the information. We are looking at women's health care in regard to the eighth amendment of the Constitution. It is very important that we hear from as many witnesses as we can who are relevant to the proceedings. In fairness to Deputy Mattie McGrath and Senator Rónán Mullen, they suggested two advocacy groups in that area early on. We agreed as a committee that we would have TMFR and the group I have just mentioned, One Day More.
This is a very important clarification on all areas of expertise. I will allow the Deputy more time to put questions.
I had allocated time to raise these points for the simple reason that we need everybody to feel that we have listened to all sides and that all members of the committee want to hear all sides of the argument; that committee members do not have a preconceived idea or want only to hear one version. We are here to listen to all sides. Whether the people who were invited decide not to take up the offer to come before the committee, they are doing their own community a disservice by not coming before us to make a presentation.
What are the main socio-economic factors that need to be addressed in this country in order to reduce the number and the impact of crisis pregnancies, irrespective of whether the person chooses to have an abortion or to keep the baby?
Dr. Caitriona Henchion:
Some of what I have already said covers that. Access to good quality sexual health education and access to contraception are two of the major things. There is also the issue of why women would feel they are unable to continue with a pregnancy. Perhaps in some ways there are lots of other issues that come in there - the support for women who are still in education who might have a baby might not be what it should be; similarly consideration should be given to increased flexibility in work practices to enable women to feel that they are not going to be discriminated against in terms of promotion if they have to take time off to have children. Those are two very clear factors.
More social support for women who are in very seriously deprived situations, such as the women who might have children in care should be available, so that they are not made to feel that having another pregnancy will deprive them of the opportunity to be reunited with the children who are in care. These are all very complex issues but those are the types of issues that fewer women felt meant they could not actually continue with the pregnancy.
In her presentation, Dr. Henchion stated:
And we cannot ignore the fact that socio-economic factors frequently determine whether a woman ultimately travels for a legal abortion or resigns herself to the reality that her only option is an illegal abortion.
Dr. Caitriona Henchion:
Absolutely, it is going on. I definitely see women who come in who have had an illegal abortion. They have found somewhere online to order pills and have taken those pills at home. The only ones I will see are the women who are concerned in some way that perhaps something has not gone well. The evidence would be from the number of packages that some of the providers have sent to Ireland and from some of Dr. Abigail Aiken's evidence that there are a considerable number of women doing this on a daily basis in Ireland.
The reason I will see these women is because they have sat at home worrying about whether they have bled enough, and whether that they have had an abortion or not. The women do not feel well, they have cramps, pains, things are not settling down and they are wondering if something has gone wrong or they are bleeding too much and are wondering if something has gone wrong. I see women who have been in these situations and they are accessing abortion pills in an illegal way and taking them. Because they are taking these pills in this country, that is illegal. That is definitely happening.
When these ladies present to Dr. Henchion or to one of the units around the country, I know there is a consultation with Dr. Henchion but is there a follow up to the HSE, to the hospitals or anything when a woman finds herself in a position where she needs further care? Are there support mechanism for a person who is too far advanced in her pregnancy to be taking an abortifacient?
Dr. Caitriona Henchion:
Somebody could present to any doctor, but if she presents to me and I take the history and do an examination, and if the examination suggests either that there has been a complication or that the pregnancy has not ended, then usually what I would have to do at that stage would be to refer that woman on for evaluation in a maternity unit, where there is access to scanning. That is the next important stage, to find out what exactly is the situation. In my position, we have two clinics, so I would have two particular hospitals that I would refer women to. I would always contact the hospital to explain the woman's situation, so that she does not just arrive to an emergency room and have to explain her story to several different people. That is not necessarily universal. That is what I do. I have made those contacts to ensure that we can provide that pathway for women. I have had women who have delayed coming and when I suggested that they need to go for further evaluation in a hospital, they have specifically asked me whether they will be reported. It is a real concern not an imaginary one. People actually ask that question. They feel that even though the doctor might not want to report them, the doctor would have no choice because they have committed a crime. It is a concern that they are not presenting when they need to be seen.
Deputy Rabbitte is fine for time. The exhibit that is on the screen is from a presentation by Dr. Abigail Aiken, who we asked to attend as a witness, following on from Ms Justice Mary Laffoy having pointed out that this was an issue we needed to investigate further because they did not get to spend as much time on it during the deliberations of the Citizens' Assembly. That may be of assistance in terms of the number that Dr. Aiken has been able to collate.
I will now call the next questioner. Deputy Peter Fitzpatrick has ten minutes in total and he can use it in this session and the next. He can let me know.
I thank the Chairman I thank the witness for her presentation today. Let me begin by clarifying a few matters. The Irish Family Planning Association is affiliated with the largest abortion providers in the world, the International Planned Parenthood Federation. Am I correct that they fund some of Dr. Henchion's activities?
Mr. Niall Behan:
I am answering the question. We have worked in partnership. It has given us funding to hold events. That was very clear in Leah Hoctor's presentation. She was very upfront about that and very clear. I do not see what the problem is. We are a health care organisation. We will work with other reproductive health care organisations. That is what one would expect.
Here in Ireland, the Irish Family Planning Association is officially signed up as a member of the coalition to repeal the eighth amendment which is running a nationwide campaign to repeal the eighth amendment. Is that right?
We all know about couples who would love to adopt a child in Ireland but there are no children available to adopt. It is very much a silent pain experienced by many people throughout the island. As a politician, people tell me we would be better off spending our time and efforts to bring experts from abroad to look at ways of simplifying the adoption process in this country, which is quite complicated at present. What specifically is the Irish Family Planning Association doing to promote adoption? It is funded by taxpayers' money. What percentage of the tax funding goes on working to improve adoption services compared with spending on promoting the campaign to repeal the eight amendment? Will Mr. Behan tell us how many conferences his organisation has held? How many experts from abroad has it brought in to talk about that? How can it improve the services in Ireland?
Mr. Niall Behan:
There are lots of questions there. I will have to give a fairly thorough answer to them. When a woman presents in our counselling centres, we go through all the options with her. That includes parenting, abortion and adoption. Very few women opt for adoption but they have done so. We work very closely with other adoption agencies when that happens. The counselling we do is non-directive. If that is what the woman wants to do, we will help her work through it and work with the adoption agency but also parenting organisations. In answer to some of the issues Deputy Rabbitte raised, we have plenty of women who present to us with an unintended pregnancy but they decide for various reasons to parent or, very rarely - I can only remember about two cases in the past couple of years - go on to look at adoption.
Did the Irish Family Planning Association spend any money asking people questions about adoption? It brought in experts to help with the campaign to repeal the eighth amendment? Did it spend any money getting experts in to talk about adoptions?
Mr. Niall Behan:
Our counsellors are the ones who work the protocols. In the past, they have had training days and information on Irish adoption laws. There have been some changes in Irish adoption laws over the past few years. Adoption has changed. They have had training sessions and our protocols have changed to reflect those legal changes.
My second question is about the counsellors. Was Mr. Behan aware that some of the Irish Family Planning Association clinics were found to be engaging in a dangerous practice in recent years, specifically in 2012? I will not go into detail but some of the counsellors were found to be telling women they could tell lies to doctors by telling them they had miscarriages rather than abortions. The master of the Rotunda at the time said this would put a woman's life at risk. Mr. Behan talked today about being able to look after women's health properly and about looking after them to the highest health care standards. Does Mr. Behan think the counsellors who told these women they could lie to the doctors were meeting the highest health care standards?
The matter went as far as the DPP. It is on the public record. The DPP decided not to prosecute. I did not object to the witnesses coming in today but I can refer to what happened. I am asking the question.
Dr. Caitriona Henchion:
I am quite happy to address that. What the Deputy is referring to is the operation in which women who were not pregnant attended pregnancy counselling services and, without either the knowledge or permission of the counsellors, recorded those consultations, which I find very unethical. From all of that, they isolated a few phrases in which counsellors had been led into giving specific answers and took them completely out of the context of an otherwise very professional consultation. As the Deputy said, this has been investigated by the HSE and a file was sent to the DPP and there has been no evidence of wrongdoing found. I do not know that one can say we did anything wrong in this situation. Furthermore, it is the restrictive criminal laws that are making women afraid to disclose their medical history when they go to hospitals. It is the restrictive criminal laws that mean women are looking for information about websites when they come to see counsellors. It is those restrictive laws we need to change.
In fairness, the counsellors did talk about telling lies. That is totally wrong. Most of the witness's statement today was about the health care of the woman. It is wrong for counsellors working for the Irish Family Planning Association to tell people to do this. I spoke last week about Marie Stopes paying bonuses to staff members to encourage people to have abortions. That is totally wrong.
The witness has talked about how a woman who travelled abroad for an abortion will not be able to bring her medical history with her. Medical history is very important so that a doctor can treat a woman properly. If she has any complications or problems, he knows exactly what he can do because he has the records. If women who went to Irish Family Planning Association clinics followed the advice they got there and told doctors they had a miscarriage instead of an abortion it would mean giving false medical history and if any complications cropped up, doctors would not be able to treat them properly because they would not be aware they had had an abortion. Given that medical history is very important, why were counsellors in Irish Family Planning Association clinics telling women they could give false information to their doctors. How can the organisation tell us women's health is very important? I am very disappointed. People do not just make these things up. People went in looking for advice from the services. The Irish Family Planning Association is the only agency that was invited in here and it has told people to tell lies and put women's health at risk.
Dr. Caitriona Henchion:
I have answered that question to the best of my ability. It is the law that is causing these problems. If we are going to have a situation in which women are going to feel criminalised in they disclose their history then women will not want to disclose their history. If we have a situation, on the other hand, where we are not allowed to make a referral and provide information, it is also the law that is preventing that. The law and the criminal sanctions that are in place are what is leading to all the failures of care the Deputy is describing.
Since the introduction of the eighth amendment, there have been no prosecutions of doctors or other medical personnel. All I am trying to say is that one aspect of this debate really annoys me. As the Chairman knows, I say every week that Ireland is one of the safest places in the world to have a pregnancy. I think it is an absolute disgrace that counsellors from the agencies that are coming in here are encouraging patients to tell lies. It is a pity we do not have someone else coming in here to agree with everything I have said so far.
I do not feel as though I am getting a proper answer from those who are here today. To me, anyone telling a woman to tell a lie - to say she is having a miscarriage instead of an abortion - is an absolute disgrace.
The biggest problem we have at the moment is that as far as people are concerned, abortion is going to be on demand as a result of the vote we took here last month. I felt that a lot of pressure was put on members to vote. It was totally and utterly wrong that we took that vote. The Citizens' Assembly did not vote until it had completed its hearings. We should have done exactly the same.
Now the time is up. I do not want to get into a debate about this while we have witnesses in the room. With respect, we can have a debate about this at another time if the Deputy wishes. There will be a more appropriate opportunity. I do not wish to cut the Deputy off, but it is not appropriate to get into this subject right now.
I would like to preface my remarks by referring to what Deputy Rabbitte said. I think the Chair said she is "indebted to Deputy Rabbitte" for her comments about the non-appearance before the committee of certain pro-life invitees. To judge by the letters sent in by two of them, they did not want to be used in a tokenistic way by a committee that had already made up its mind that the eighth amendment must be changed or removed. That was a significant decision to take without hearing all the evidence. The response of the invitees in question was very understandable. They did not wanted to be added in as a last-minute sprinkling for respectability by a committee, especially as their presence would not reverse the 26-4 or 27-4 bias among witnesses. That is the answer to Deputy Rabbitte's concern. I think the blame lies squarely with this committee. I do not think the Chair will be indebted to me for saying that, but the evidence is incontrovertible.
When the Chair is tweeting online and supporting comments by other members of the committee who are having a go at members of their own party, I think it raises questions. If she does not mind, I would like to ask my questions.
The Chair is the one who sought to have the final say on what I said, which was very carefully worded and 100% truthful. She was not willing to let it go, notwithstanding that she had already expressed her opinion very clearly. That reflects on her attitude, not mine.
Appendix 2 to the IFPA document says that "IFPA services are operated in line with best international practice". In light of that, I want to go back to some of the issues raised by Deputy Fitzpatrick. An exposé that was reported on in the Irish Independenta few years ago was done by a group of women who had anecdotal or personal experience of having abortions or who knew women who subsequently came to regret their decisions and felt they had been badly and, in some ways, illegally advised by counselling agencies in receipt of funding from the State. This is a very serious matter. It was investigated by the Garda. The evidence showed that women were told to hide their abortions from their own doctors on five occasions. In four of those five cases, it was IFPA counsellors who told them to do so. In one case, a woman was told that if complications arose after a surgical abortion in Britain, she needed to tell medical staff in hospitals that she had had a miscarriage. Nothing was said to her about whether she would be criminalised. There was no evidence that this would ever happen. I think the strong understanding of people is that it would never happen. She was simply told she needed to tell medical staff she had had a miscarriage, as opposed to an abortion.
The then Master of the Rotunda Hospital, Professor Sam Coulter-Smith, criticised the danger surrounding this type of advice. He said that complications during an abortion procedure could result in perforation of the uterus, which could be life-threatening if not known to the woman's doctor. I put it to the IFPA that this was the action of a rogue agency. It did not just happen once; it happened on at least five occasions and the IFPA was involved on at least four of those. Contrary to the implicit suggestion that the counsellor was an inexperienced person who was led into giving this advice, in the case of one Dundalk-based counsellor it was a very experienced person. Does the IFPA deny that what was recorded took place? Why has it never issued a statement acknowledging wrong practices within the agency or, indeed, proposing to make amends? Was that not very reckless?
On page 4 of its presentation, the IFPA clearly criticises the importation of abortion pills as dangerous and describes this as "an unregulated and unsafe practice". On the occasion of the investigation to which I have refer, women were told at two IFPA clinics how to purchase and import illegal abortion pills by visiting a named website. One counsellor advised a woman that she could have such pills posted to a post office box in Northern Ireland. A counsellor at the Cork IFPA service who discussed the illegal importation of the abortion pill with a woman emphasised that the IFPA was not encouraging her to break the law or get into trouble while pointing out that this could be done. The counsellor got the woman to write down the relevant information because he or she did not want to be arrested for providing it. The counsellor was aware that this was not the kind of information he or she should be providing. Is that not also the action of a rogue agency?
I will summarise my questions. Does the IFPA acknowledge that there is evidence that some of its people have engaged in actions that were fatal for unborn children and had potentially dangerous consequences for women? While this evidence was reported to the Garda and led to some commentary in the Dáil, the Seanad and at the Oireachtas health committee, the IFPA neither deigned to issue an explanation of past wrongdoing nor showed any desire to investigate or to get to best practice. Does that not show how little the IFPA actually cares for women's health? The report or investigation I have mentioned also found that Marie Stopes was criticised by IFPA counsellors, who advised people not to go to Marie Stopes services because they had received many complaints about them. If the IFPA really cared about women's health, would it not have gone public about this matter rather than quietly advising people not to go to Marie Stopes? Would this not have been seen as a public health and safety question? I would be very grateful for answers to those questions.
Mr. Niall Behan:
Many of the statements that have been made are absolutely incorrect. I think an attempt is being made to stigmatise a service provider. The first thing to say is that no group of health care providers that I know of is more committed to women's reproductive health than IFPA counsellors. They make a conscious commitment to the women they deal with when those women are making their choices. We put ourselves out there even though we are facing a difficult situation with regard to the law and the presence of anti-abortion campaigners. That is the first thing to say.
The second thing to say is that I welcome this opportunity to put the record straight about matters that have been raised a couple of times in the Oireachtas and, indeed, in the media. We have not had an opportunity to correct the record. The facts and figures given by Senator Mullen are completely incorrect.
The facts and figures that Senator Mullen cites are completely incorrect. I was called into the Garda investigation and I worked very closely with the HSE audit team. The Garda investigation was absolutely clear that in regards to the Irish Family Planning Association, IFPA, there was no wrongdoing whatsoever. I repeat, no wrongdoing whatsoever. I do not know what else Senator Mullen wants.
Mr. Niall Behan:
There was a HSE audit parallel to this. I should explain what it was. It did not just concern the IFPA, and this is the difficulty I have with some of the input from Senator Mullen. I cannot speak for other pregnancy counselling agencies. What I do know is that the Garda spoke to two of our counsellors about these transcripts, not five, four or nine of them. Quite frankly, the gardaí were embarrassed to be investigating this nonsense. This was a set-up, a sting operation by anti-abortion campaigners trying to lead counsellors to break the law. It was nothing more and nothing less. What we had parallel to the Garda investigation was a HSE audit-----
Mr. Niall Behan:
In parallel to the Garda investigation, the HSE carried out an audit. That audit looked at every one of the IFPA counselling protocols and at the protocols and policies of the other HSE-funded counselling services. We were asked to justify various procedures we had in place. The audit examined the evidence that we relied on for those protocols from a whole range of best practice models; the World Health Organization; the Royal College of Obstetricians and Gynaecologists; the International Planned Parenthood Federation; the Irish College of General Practitioners; the HSE itself; and the Irish Association for Counselling and Psychotherapy. That is how the audit proceeded, by looking at how we actually did our work.
This was carried out by the quality and patient safety directorate within the HSE. The IFPA had no difficulty in co-operating with that process. It took up quite a lot of IFPA and HSE staff time. Following that process, four administrative recommendations were made to us. We had no difficulty in complying with them. Within days of receiving those recommendations, we changed our protocols in a manner that was satisfactory to the quality and patient safety directorate. This is the type of stuff that the IFPA has been putting up with since the 1970s. It does not deter us. I do not know why Senator Mullen does it. It does not really get him anywhere. We stand on the evidence and on medical best practice.
Mr. Niall Behan:
While this was going on within reputable counselling services, not just the IFPA, rogue agencies were allowed to practise. Women were going into rogue agencies that had absolutely no scrutiny or legislation to call them to account. That makes the law a shambles. When there are organisations relying on best practice to provide these services, and the law only applies to them and not to rogue agencies, that is a shambles.
I will, and thank you for the opportunity. I have not got an answer to any of my questions. I heard an explanation that the HSE investigation came up with recommendations that the IFPA had no problem with implementing. I did not ask about that. I did not ask what they thought of the gardaí who were carrying out the investigation. What I have heard from Mr. Behan is the suggestion that some of what I have put to him is false. I want to ask him which of the issues that I have put on the record, and about which I have asked him, is false. Does he deny that on four occasions, IFPA counsellors told women to hide their abortions from their doctors? Does he deny what I said about the experienced counsellor in Dundalk, who gave the specific advice that I put on the record? Does he deny that he has never acknowledged any of these wrong practices? He thanks us for giving him the opportunity to put certain things on the record. The point here is that in four years, the IFPA never took the opportunity to explain itself, or to deny one iota of what this investigation brought to light.
I thank the witnesses for their presentation. I felt it was very useful. Obviously, we are trying to focus on the recommendations from the Citizens' Assembly and come to a conclusion in the writing of our report. I would like the issue of bias to be dealt with at some point, perhaps next week. This concerns the names of the organisations that have come in here. A large number of witnesses have appeared, and they have given neutral legal advice. We need to address that. I ask the Chair that the committee address this next week.
We can have a half an hour of debate on that at the start of our next meeting. In fact, I would be very grateful if that was addressed. It is very easy for something like that to resonate, and it is much more difficult to defend against that type of allegation.
Moreover, it is not true and it is continually being put out there. Mr. Behan said that his clients are increasingly women who experience multiple forms of disadvantage, which in turn restricts access to abortion. It was very useful to see the profile of women who seek abortions in Dr. Abigail Aiken's presentation. A view is sometimes put forward that there is a frivolous aspect to women who might be seeking abortion or that it is a form of family planning. I am playing devil's advocate in this. Personally, I think that nobody would seek an abortion unless they had seriously thought about it and it was a serious crisis. I would like to ask the witnesses what they hear about the thought that goes into abortions. Obviously, there is a non-directive counselling service in advance.
Will Dr. Henchion address the issue of people being thoughtful about the very big decision they have to make?
Dr. Caitriona Henchion:
Undoubtedly women give the decision an awful lot of thought. It is not only women, however. Quite often families are involved in the decision, women and their partners, and they take into account issues relating to their children. I have spoken to women who, very regretfully, decided to have an abortion because they already had two children with special needs and simply would not have been able to look after them properly if they continued with another pregnancy. I have come across women who have made their decisions with great difficulty, but after giving them a great amount of thought. They may feel, for example, that there is a very high risk of a problem occurring with their pregnancies by virtue of their age. In every case, the women have considered the decision. They have argued for and against it in their heads for quite a long time before making it.
The other issue is that so many of these women are not using contraception properly or not using reliable contraception at the time they become pregnant. Quite separately from women who have had a crisis pregnancy or an abortion, I meet many women for emergency contraception or contraception consultations. Sometimes I meet women for consultations that are totally unrelated to contraception and when I ask them what contraception they are using, they tell me that they are not using any even though they are of reproductive age. The issue of why women are not using contraception or not using effective contraception is a huge issue which needs to be addressed. I have given some of the possible reasons for that.
This is not just to do with teenagers and young women. This is to do with women of all ages having misconceptions about their fertility or simply taking chances, putting off issues of contraception and not doing anything about it. We really need to address that. It would be far better to reduce the number of unplanned pregnancies and crisis pregnancies rather than having to have an increased number of abortions.
I thank Dr. Henchion. In respect of people accessing medication online, she has said that abortion is a relatively safe procedure, but it is obviously not safe in every set of circumstances and needs to be carried out in a health care context. What kind of risks are we talking about? With specific regard to pills ordered online, is there a health risk or a risk to life? Will Dr. Henchion articulate any such risks?
Dr. Caitriona Henchion:
There are a number of risks. The first is that the medication may not be what it is supposed to be. That is particularly the case if ordered from a provider that is not reliable. I have seen women who have taken medication they ordered online themselves and nothing has happened. The did not have bleeding or pain or they had had very little bleeding. It is clear that whatever they were given did not contain any active ingredients. We have no idea of the conditions in which that sort of medication is being made. It may not be safe. It may contain ingredients which are not safe for people to take. It is certainly misleading and it gives women the impression, particularly if they have a small amount of bleeding afterwards, that they may have ended their pregnancy when in fact they have not. In the event of someone being at a later stage of gestation than she thought, there is a greater chance of the medication not working and, therefore, a greater chance that the pregnancy will continue. It is dangerous to expose a pregnancy to some of those medications if it then continues.
There is not a huge number of complications in these cases, but there is one very simple thing about which I would be concerned when women are accessing pills online. If anybody who has a miscarriage, abortion or full-term delivery is rhesus negative, which is a blood type, she needs to get anti-D immunoglobulin to prevent damage to any subsequent pregnancies. These women are clearly not getting that because they are not seeing a health care provider. My final concern, which I have already mentioned, is the fear that the small number of women who have excessive bleeding are delaying coming to see somebody because they are afraid of getting into trouble.
Following on from that, if the medication is not what it is supposed to be, does it pose the prospect of later travel and an abortion being procured later as a consequence of that delay? Is that scenario likely?
Dr. Caitriona Henchion:
That could certainly be a problem. As I said before, we only see a small number of these women because we are not likely to see women who do not have problems. Even when they do have problems, they may do nothing rather than risk coming to somebody who they feel might report them. I can only guess that it might be a factor in delaying access to abortion.
Dr. Henchion has given a very comprehensive presentation and many of my questions have been answered. I would just like to clarify or confirm what I have picked up from her responses. From her experience with unplanned pregnancies, does Dr. Henchion think that our sex education programme in schools is effective? Is there enough knowledge about the effectiveness of various forms of contraception out there? I believe Dr. Henchion has basically said that, in her experience, there is not but I would like her to clarify that because it is important that we get a clear message out in respect of sex education and awareness around contraceptives.
Dr. Caitriona Henchion:
The problem is that our education system is inconsistent in respect of sexual health. There are schools where it is done really well and schools where it is barely addressed at all. It sometimes happens a little bit too late, so the very vulnerable people who might leave education early are not getting access to such education at all. That is my view.
Finally, I would like to ask Dr. Henchion about so-called agencies which are not funded by the State - rogue agencies. Does she have any experience of adverse outcomes caused by the involvement of such groups in a crisis pregnancy?
Mr. Niall Behan:
If I may add to that, we have had a small number of cases of pregnancies that became concealed pregnancies because the first experience of the young girl or the woman with a service was so negative that she did not present at any service subsequently until very late in the pregnancy. They move into that kind of concealed pregnancy and do not engage with maternity services. We have had a small number of such cases.
I thank the witnesses for coming in today. To follow on from some of Deputy Daly's questions on contraception, I hope the witnesses will correct me if I am wrong but I believe they are saying that greater access to contraception leads to fewer unwanted pregnancies. Can we sum it up like that? I have tabled a parliamentary question on today's Order Paper, No. 76, which basically asks the Minister for Health the cost to the Exchequer of contraceptives over the past ten years. I did not table the question just for the good of my health. I intend to propose that all women in Ireland be provided with free contraception, in the same way as proposed by Deputy Daly, to whom I have spoken about it. I worked in community pharmacy before and we had difficulty in accessing emergency contraception at the weekend and the Minister introduced a statutory instrument. Based on what the witnesses have said today and the work which has already been done by members of the committee, it is a no-brainer for us to call for universal access to contraceptives for women in Ireland.
Dr. Henchion referred to long-acting, reversible contraceptives. The cost of the Mirena coil allowed on the drug payment scheme is €144, providing coverage for five years, give or take, which is €2.40 per calendar month. That is not a massive sum of money. Dr. Henchion is talking about the outlay. I have come across people who have put off having the relevant procedure for financial reasons.
We are discussing socioeconomic reasons today but I want to move away from the economic element to the social one. One of my sisters had babies in that wonderful hospital in Cork. I was interested to see that domestic violence goes from one in eight in normal circumstances in Cork, or the regions served by Cork, to one in five when a woman is pregnant. My understanding is that economic factors have no influence on this. The committee needs to know that women are much more likely to suffer from domestic violence if they are pregnant. I should not say that is not only in Cork. However, the study was conducted in Cork and the surrounding region. What emerged from it conjures up the idea that women with crisis pregnancies may be trapped in relationships where they are forced to become parents against their will. Can Dr. Henchion tell me if there is any impediment to a woman's requesting a hysterectomy? If I decided tomorrow that my periods were too heavy or too difficult and I was low in iron and wrecked all the time, would I have to go to a court to ask that my reproductive organs be removed? Do I have to clear it with anyone other than my doctor?
Referring to something my Fine Gael colleague said, that we do not have any babies to adopt, are we moving into a situation reminiscent of The Handmaid's Tale, whereby women with crisis pregnancies will be detained, forced to become parents and used as a source of supply of babies for childless people? That is up there with the most shocking thing I have heard today and I am hoping to God nobody forces me into that situation. Good luck to them if they do.
I want to correct something that was said by the good Senator Mullen. The Irish Independentdid not carry out the investigation into the doctors. I believe it was an undercover operation by anti-choice activists and the story was then given to Gemma O'Doherty of The Irish Independent.
Grand. We will check the Official Report.
I think it was Deputy Rabbitte who asked about illegal abortions and Dr. Henchion spoke about online pills. Have we any evidence that illegal surgical abortions are taking place in Ireland? My mother tells me that back-street surgical abortions were available here in the 1970s.. Has Dr. Henchion come across evidence of this? I do not believe it has come up at the committee to date. Have we any evidence that the coat hanger tricks are going on in the back streets in Ireland in this day and age?
Dr. Caitriona Henchion:
I will take the last question first. Thankfully, we do not have any evidence of back-street surgical abortions. In response to the second one about what women have to go through to ask for a hysterectomy, first, it would not be an appropriate operation for fertility control. There would be surgical sterilisation operations available to women where the tubes are tied or ligatured. That is available but logistically it is not very practical because it takes probably over a year for a routine gynaecological appointment to come to the top of the list. Then, having been seen, the woman may be rejected on the grounds of not enough children, too young or various matters like that. The woman is then put on a second waiting list - to actually get the procedure done - if that is deemed to be suitable. There are women who want a permanent method and do not want to have to keep on renewing contraceptive methods. I would always say that I refer them but they need to do something else now because they will be waiting two to three years for that to become a reality.
Does anybody intervene, apart from in the context of the conversation between the woman and her doctor to stop her having that procedure? Dr. Henchion mentioned not having enough children. Who deems that an appropriate question to ask a woman of sound mind?
Dr. Caitriona Henchion:
Historically, there would have been ethical committees in hospitals in which those operations were performed. Those committees would have said women had to meet criteria in order to qualify for sterilisation. In reality, the point is that it is now between the woman and her doctor but it is a permanent method and the woman cannot change her mind. The effectiveness of it is no greater than, for example, having a Mirena coil fitted. We would generally much prefer to recommend that they have a Mirena coil so that they are at liberty to change their minds at any stage in the future.
I thank the witnesses for their presentation and previous replies. For a while it felt as if they were on trial. It is an awful shame to sit on a committee like this, which should be about women and how women are affected, and have the conversation dragged away from that and off in another direction.
Many of the questions I intended to ask have been answered but I would like to tease out some of the socioeconomic reasons. As a recommendation, there is probably a lack of understanding of what that means. Initially I recall celebrating this recommendation from the Citizens' Assembly. I received commentary to the effect that it referred to poverty and wanting to abort children born into poverty. There was a real lack of understanding that this concerns women who are affected in some way by their socioeconomic circumstances and that covers many issues, including mental health, addiction and age.
It is difficult to sit here every week and separate the political from the personal, particularly as a woman who has probably experienced many of the things we speak about every week. I was a service user of the IFPA. I had a crisis pregnancy and I ticked as many boxes as a woman possibly could at the age of 15. I found the service amazing. It was comforting and the counselling I received there was very good. Deputy Rabbitte spoke about representing women with crisis pregnancies who proceeded to have children. I am one of those women and I represent them here. However, this does not mean that I am of the view that women should not have a choice. I was given that choice earlier. This is not a question of the witnesses coming in here to promote abortion, which is how it is being sold. The IFPA definitely did not sell abortion to me at the age of 15. I want to put that on the record and to commend the organisation. As a community worker who works with women in deprivation, I continued to refer women who found themselves in that situation to the IFPA and I would continue to do that, no matter what is said here today.
To tease out the socioeconomic circumstances, the witnesses have some of those reasons in the vignettes. I want to capture today not the barrier to women travelling - because we know that the socioeconomic situation is a factor - but how we begin to create criteria that encompass everything that socioeconomic status can affect. That exists in other countries. What falls under it and how? Is it impossible and should we just go for it without restriction? If we do not have a ground for socioeconomic reasons should we increase the number of weeks for providing it without restriction because sometimes those socioeconomic factors might not come to light until later?
I probably have not been very clear. It is difficult to separate the personal from the political when I sit in this room. Perhaps we can speak more to the impact of socioeconomic status on women's decisions. The witnesses referred to women's aspirations and, for example, a woman wanting to go college and being the first person in her family to do that. Will people take seriously the fact that women seeking abortion are likely to talk about their own aspirations and what they want in terms of quality of life? How do we capture that in a doctor's waiting room?
Dr. Caitriona Henchion:
On the subject of how to decide what is a socioeconomic ground and how could that be put into a legal framework, I think I have already said that is a very difficult thing to do.
I think it would probably also take a lot of time to do. If somebody feels that in her particular set of circumstances she cannot continue with the pregnancy, we have to trust her. In having a consultation with somebody, we have to trust that those appear to be real concerns and that is the decision the person has made. Obviously, if somebody is not actually certain of what she wants to do, then it is not anybody's role to try to convince her to go in one direction or another. The role of any consultation, any first contact, will be to identify those women who need more support with their decision and make sure that they get those supports, whether they are financial, practical or more counselling and more time. That is really where the important thing comes in about identifying socioeconomic problems and making sure that those women get the resources so that socioeconomic factors do not necessarily have to be deciding factors in what they do about their crisis pregnancy. I think trying to come up with a whole load of socioeconomic grounds that would then allow an abortion is not the way to go and would not be helpful.
Thank you Chairman. I thank our witnesses for their presentation. I only asked the question to find out more about the basis on which they come to their conclusions. In respect of counselling, the IFPA gives non-directive counselling. Can Dr. Henchion give some information about the number of women who might have already made up their minds as to what they are going to do before they came for counselling and afterwards? Can she give a general ballpark figure?
Mr. Niall Behan:
We have seen a shift over the last couple of years. At one point, we had a lot of women who came to our services with their minds made up. They were coming to our services for telephone numbers and addresses for abortion clinics in England. That has changed because those numbers are more easily available. What we tend to get these days is some women who have made up their mind about what they are going to do, but have a particular obstacle in their way or a particular issue that they want teased out - for example, if it is abortion, the issue could be around which procedure they might go for. They are looking for particular information. In respect of women who have not made up their mind and come to the counselling session, I would say around 50% of the women who come to us still have unresolved issues they want to work through. They could be leaning towards a particular option but they still have issues they want to know about and work through.
What is the age profile of the women who attend for counselling? I know the witnesses have already said that they work with women who have already had children and those who have not. Roughly what is the proportion of women with existing families and those without? I know the IFPA deals with rape situations as well. To what extent does that continue to be a feature of the people the IFPA counsels, and of their age profile?
Mr. Niall Behan:
There is a misconception sometimes that the women who come to our services are teenagers. The vast majority of them, roughly 75%, are between the ages of 24 and 34. Around rape, we have very few clients coming to us following a rape. The number is very small. We work very closely with other agencies such as Women's Aid if it is a domestic violence issue, or the Rape Crisis Centres. We also provide post-abortion support. If women who do travel for an abortion then come back to us, we can provide post-abortion counselling. That counselling is usually about the context in which the unintended pregnancy happened. It can be about a rape, a relationship breakdown, whatever the reason that led to the pregnancy being a crisis. Dr. Henchion and our team of doctors provide the post-abortion medical checks that go alongside the counselling.
Senator Ruane made an interesting reference to comforting women. Previous generations in this country really ignored women and girls, in particular, who were pregnant, and cast them out from society, isolated and criminalised them to a huge extent. Do the witnesses see the services they provide, in particular counselling, as providing something that is vital and necessary in attendance with pregnancies of a crisis nature, regardless of whether the woman has had an abortion, wants an abortion or goes through with the birth?
Dr. Caitriona Henchion:
Absolutely. The feedback from the women is very much that it is a really big support at a time they did not feel supported. One of the things that counsellors do very well, particularly in what is admittedly a very small area where there might be very teenagers attending the service who might have initially attended not wanting to involve anybody else in the situation, is working with them to involve their parents and other family members and making sure they are getting the wider support that they need, whatever decision they might come to.
A reference was made earlier to online services. Let us assume for example that the service was legalised. From a safety point of view, how do the witnesses feel about it? The online part of it is what would worry me, that the degree of advice-----
I am coming to it. The amount of advice or instruction that might be available is lacking and the person, young woman, girl or whatever, might have insufficient information and might be at risk as a result. Can the witnesses quantify the extent of that risk?
Dr. Caitriona Henchion:
I think it is very difficult to quantify but there is no question that they are not getting the opportunity to sit down and discuss their concerns with another person at the outset. That is the first part they are missing. Then there is not that very solid advice of "if this happens, this is where you go and it will be fine if you go there". That is the other part that is missing. There is no nice, easy follow-up care when anything does go wrong. Obviously, then, they are not getting their contraception either.
Definitely. We have seen statistics produced in evidence to the committee comparing Sweden and Switzerland, both developed countries with similar societies, which indicate a huge difference in the numbers of abortions taking place. Do the witnesses have any knowledge as to why that might be?
Mr. Niall Behan:
The best statistics that we go on are the ones we get from the Department of Health in the UK. They relate to women who give Irish addresses to abortion clinics, mainly in England. We see a trend. After 1983, after the amendment is passed, we see those figures going up and up. We see the eighth amendment making no impact on the number of women travelling to the UK. When we get to 2001 and 2002, however, we see a change, a reduction. It is an interesting point. Why have we got this reduction? Why have we got this doubling of the figures in the 18 years after 1983 and then a reduction in the last 16 years that is almost consistent across all the years? The thing we can point to is the policy changes, the political consensus that we had here between Fianna Fáil, Fine Gael, the Labour Party, the Independents and the left wing parties in the 1980s around this attempt to improve sexuality education.
Access to contraception and the establishment of the Crisis Pregnancy Agency has had a huge impact. We can go much further in that regard and get much better access to contraceptive services and improve sexuality education. The law does not impact on those rights but makes it more difficult and is more harmful to children.
I also thank the Irish Family Planning Association for the role it has played and for the provision of women's reproductive health in Ireland. The service has been around a long time. I used it in the 1980s during much darker days for women in terms of accessing reproductive health care. I was afraid to go to my doctor to ask for a coil or the morning after pill and I shared such fear with many women of my generation because we were in those dark times during the 1980s. If one could not afford a private clinic, the only place one could go was the Irish Family Planning Association and it continues to play that role. I will never forget the helpless bewilderment on the faces of counsellors when I told them I wanted an abortion. In those days they could not even give me information on how to go about that because it was before the Regulation of Information (Services Outside the State For Termination of Pregnancies) Act 1995 and it was illegal to give me the phone number of an abortion clinic in Liverpool. I had to get that number under my own steam. I thank the doctors, counsellors and those who worked tirelessly for women over the past decades and provided those services throughout the country. In many cases it was not just in respect of contraception but general sexual health.
As regards the socioeconomic point and the question of the increasing number of women who are in crisis pregnancies because of poverty, do the witnesses have any evidence that poverty impacts on the level of crisis pregnancy? The lack of access to proper contraception such as the permanent reversible contraception of which the witness spoke is a contributory factor. I think it important to repeat something Dr. Henchion said in her submission. She said: "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". Is it not a huge indictment of the services here that we are supposed to be concerned about the protection of life in our laws which say we are concerned about the foetus and the unborn yet socioeconomically we are condemning more women to crisis pregnancies because of the inaffordability of proper contraception? Can the witnesses confirm if that is the case?
An alarming statement made by Dr. Henchion which flies in the face of what was said about Ireland being one of the safest countries in which to be pregnant is that the increased clandestine and illegal use of the abortion pill means more and more women are left without follow-up post-abortion care. She also said that many of the women she sees do not come back to the IFPA for post-abortion care. Perhaps she could explain why that is so. I suspect it is related to the socioeconomic poverty reasons I have mentioned. Are those who say this is the safest place in the world in which to be pregnant taking into account the IFPA statement which says that a substantial number of women are accessing illegal abortions through the abortion pill and, therefore, do not have follow-up 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." That is an extremely strong statement. I would like the witnesses to expand on how we, as a society, are leaving ourselves and society as a whole but women in particular open to severe consequences through ignoring their reproductive health in this manner or making it illegal for them to take certain actions.
Dr. Caitriona Henchion:
One of the first things one has to do for a health measure to be widely adopted is to get rid of cost. That is what we do with vaccination programmes. One could point out that if people valued it enough they would still get it but if one wants everybody to do so, one must get rid of the cost. That is what is done for public health issues. If we want to tackle the issue of crisis pregnancy, contraception and sexual health education has to be looked at as a public health issue and money must be taken out of the equation in order that it cannot be a factor.
It is not enough to only take out the cost of contraception. One needs to make people aware of the issues involved or they will not access contraceptive services in the first place. That definitely links in to socioeconomic factors because, as I said, a girl who leaves school early may have missed out on contraceptive education at school because it might have been delivered too late. A girl who does not attend school very frequently may not have received that education. We need to address that issue and ensure we are looking at it as a public health measure.
There are many reasons why women do not come for post-abortion care. It is a difficult question to answer because if they do not attend, I do not see them and, therefore, cannot answer completely for those who do not come. Some women come to the IFPA and are very anxious about doing so. They are anxious that they may have a complication or about being judged and the attitudes that people might have towards them and are at pains to try to justify their decision because they think others might feel abortion is only okay for some people. Those are reasons that people might not want to come. Because many women do not see a health care provider before they have an abortion, in order to do so afterwards they have to again find out where that service is and then go and tell their story all over again to a new person and that is a difficulty. If they were going back to the place where they had the abortion, that would not be a deterrent. Those are some of the reasons women do not attend for care.
The risk to a woman's life as a result of an illegal abortion using online medication is exceptionally low but that is not to say that women using such medication have a good health care experience. There may be minor or low-level risks such as not getting their contraception or enduring a procedure that is painful, uncomfortable and frightening while being alone with absolutely no support and nowhere to which to turn and being worried that if something goes wrong they will be found out rather than get help. Those are examples of safety issues in terms of illegal abortion.
Deputy Clare Daly and others teased out the issue of discrimination against women in terms of being able to access proper heath care. Can Dr. Henchion comment on the number of women with disabilities or in direct provision or asylum seekers whom she sees and whether they are further discriminated against and, if so, how?
Dr. Caitriona Henchion:
A considerable number of women in direct provision may attend the IFPA. It is the easiest group to identify as experiencing further layers of obstacles and discrimination. The reason for that is that such women do not have documents. In order to get documents to travel, they must make disclosures of their situation to non-health care providers. They have to get a travel document that must be stamped in a Garda station. An undocumented migrant seeking asylum will automatically be very fearful of having to go to a Garda station. They also have to go to the Department of Justice.
They have to disclose their situation, get an entry visa for the country in which they plan to go to and a re-entry visa for Ireland. All of these documents cost money, yet, without having any income, they are expected also to be able to find the money to travel and to pay for an abortion. If they wish to seek help in that regard, they again have to make further disclosures of their health situation possibly to a charity or other agencies, from which they might try to get funding.
Dr. Caitriona Henchion:
We do not see people with disabilities very often. I think there will clearly be issues for a woman who needs a carer in order to travel, because at the very least she has had to disclose her situation to that carer. Even with something as simple as being deaf and having a limited ability to speak, how are people with these disabilities expected to ring a clinic in the UK and make an appointment for themselves, yet one is not allowed to assist them in that way.
Let me preface my two short questions with a comment, which I hope the Chairman will allow as I have not taken up too much time to date.
I have the utmost confidence in Senator Catherine Noone as Chairman, and I believe any reasonable person who has been watching these proceedings since their commencement will share that view.
On a personal level, I object most strongly to the suggestion that this committee is some type of a rubber stamp exercise. I cannot speak for anybody else but I never rubber stamped anything and I never will. I would not give this committee the credence of my continued presence if I thought that is what it was. I came onto the committee with an open mind, not an empty mind, but I want to learn. I am disturbed that some of the agencies that have been invited to come before us have chosen not to come to the committee. I am open to information. I have drilled down into the report of the Citizens' Assembly and I have studied every aspect of this committee. I want to put a stop to the legend that people have their minds made up. I am not quite sure exactly where I am on the spectrum yet.
I welcome the witnesses and I thank them for their presentation and the documents they provided, which I find useful. When a woman presents to Dr. Henchion with the intention of having an abortion, is that a matter between the Irish Family Planning Association, IFPA, and the woman in question or does she encourage or seek the engagement and-or involvement of the father of the unborn child in the first instance? Does she seek his counsel or advice? Does he have a role in this decision or is he out of the equation? If the woman in question is exceptionally young, would Dr. Henchion welcome engagement and seek involvement from her parents?
I am somewhat concerned about Dr. Henchion's statement that she has seen many women who have had illegal abortions performed. I am not quite sure what her position is on that. When a woman comes to Dr. Henchion and says she has had an illegal abortion - I would have the utmost sympathy for the woman - is it not illegal? If something is illegal, it is illegal. Does Dr. Henchion think it is incumbent on the Irish Family Planning Association, IFPA, to share that information or in any way refer it to a statutory body or State agency such as the HSE?
Dr. Caitriona Henchion:
On the question of whether we seek the involvement of the putative father in the case, the answer is "No", we do not. If a woman would like to have her partner involved at any stage, that is completely encouraged. We do not actively seek involvement of any third party in that respect. I think I already have answered the question on minors in so far as counsellors are very proactive about trying to involve parental engagement in the situation for the good of the young person and to give her support and protection.
On the question of how many women I have seen who have had an illegal abortions, I probably said that we see them, but we do not see many. We are probably only seeing a very tiny percentage of those women who are having illegal abortions, because they are reluctant to come and they will only come if there is a problem. On the question of whether I would report those women, I do not. I feel my primary concerns are their confidentiality and health and well-being. I would feel that if I were going to get into the situation where I would report them, it will deter them further from seeking medical attention. That creates a more unsafe environment for women.
The word "report" is not the word I had in mind. If I used it, I was mistaken. I asked whether Dr. Henchion would consult or engage with those agencies, because I am sure they also have the health of that woman uppermost in their minds. Maybe the IFPA would not have all the facilities that would be available to the statutory agencies such as the HSE. I am somewhat surprised that Dr. Henchion would exclude that option.
Where the partner or the putative father has become involved, has Dr. Henchion found that helpful to the woman, to the situation in general, or is it to the contrary?
Dr. Caitriona Henchion:
There is no question that a supportive partner is very helpful to the woman and to the situation in general. It makes the situation for everybody much more easy to manage. The outcome afterwards is likely to be better as well. It is much better if a person is supported through a situation like that.
I thank the witnesses for their presentations. I am sorry that they have had to put up with some of the nonsense today.
I wish to clarify a point before I begin. The Chairman will know, as indeed will Senator Buttimer, that I always find it really hard to agree with the Fine Gael Party on pretty much most things.
Deputy O'Brien is correct, pretty much everything, but I have full faith in Senator Catherine Noone as Chairman. I see her each week trying to do her best in very difficult circumstances. While we are on opposite sides politically, I could not in any way criticise how she has chaired these meetings each week. It is important that is noted because of these constant attempts by a small section of people to undermine the work of the committee.
I found the vignettes important and powerful. The members of the committee will make up its mind and make recommendations in the coming weeks. Again, we have not done that yet. If there is a referendum next year and the people vote to repeal the eighth amendment and the Oireachtas then passes legislation which legalises abortion in certain restricted circumstances, will that meet the needs of the people that Dr. Henchion is dealing with each day?
Dr. Caitriona Henchion:
I think trying to lay out specific grounds, specific risks, or specific categories of women who are somehow entitled to an abortion, while excluding others, will leave a great many women still in the same position they are in now, trying to travel for an abortion or accessing abortion online. If that is the problem we are addressing, then we will not address it if we make abortion subject to specific criteria.
My final question, which I know has been dealt with to a degree, will be brief. I am struck by the references to abortion pills and how access to these pills is increasingly widespread. It strikes me as being completely bizarre that collectively we can ignore that. Is that not bizarre?
Dr. Caitriona Henchion:
I suppose in the context that so many people access so many things online, it is not particularly surprising that if one has a service that one cannot access locally that people will look on the Internet, they will actually go online and if they find a solution to their problem, that may not be perfect in their eyes but is still a solution, they are going to use that solution. I think the only way we can address that really is by facing up to the fact that Irish women are having abortions every day and we need to actually provide those services in Ireland. Then that way we can make sure that they are properly monitored, that they are properly overseen and that they are of high standards. We can say that as a country, the HSE for example, is accountable for them, they must be of good quality.
I welcome the guests. The IFPA received €360,000 from Irish Aid over the period 2016 to 2018 for a project in Bolivia named 'Promoting the sexual and reproductive health of youth in Bolivia'. The three partners in this project are the IFPA, the Centro de Investigación, Educación y Servicios, CIES, which is a Spanish or Portuguese organisation, and International Planned Parenthood. Does the Irish Aid grant aid to the project promote abortion or does it offer abortion related services?
It does not. That is the witness's definite answer. The IFPA provides a secretariat for all-party Oireachtas interest groups on the sexual and reproductive health rights, SRHR. In an email to Irish Aid, on 4 May 2016, a Ms Maeve Taylor, a senior policy and advocacy officer of the IFPA stated that they prepared-----
Please, I would appreciate it. They prepared a briefing on the work of the CIES for the all-party Oireachtas interest group on SRHR. That is a nice sidetrack for the IFPA. Is any of the Irish Aid grant aid being used for this form of advocacy and campaigning, that is the secretarial services for Oireachtas members? Not the secretariat here, the secretariat of the IFPA and other agencies, in case our clerk is getting worried. Just clarify that please.
It is interesting to see this secretariat idea now being expanded by the National Women's Council of Ireland being the secretariat for the Oireachtas Women's Caucus that includes Ministers, Deputies Fitzgerald, Zappone and Mitchell O'Connor. Transparency I think here has been blurred and the lobbying Act may have been evaded too. I believe it was a crafty process. It was not-----
I appreciate that. However, something has to be done about it. People watching at home can see what is going on. It is a cabal and it is unacceptable and it is happening all the time. The Chair earlier interrupted because I could not hear when there was noise and talk, and she asked for-----
Mr. Niall Behan:
Yes, I am not too sure, and I mean this respectfully, what the question is. If it is a question around our work with CIES in Bolivia and Irish Aid that is very focused on what happens in Bolivia.
How many more times is this going to happen? I do not interrupt anybody or talk when somebody is talking. I leave occasionally to do other business and I get the Chair's permission. It is total disrespect. Total-----
Just let me say what I have to say. The Deputy does not need my permission to leave nor does Deputy O'Reilly, who texted me earlier to tell me she was in the Dáil, nor does anybody else who has other business in these Houses so the Deputy is no exception in that sense.
Mr. Niall Behan:
What I am saying is that we have a project with an organisation called CIES which is a Bolivia-based organisation. That is focused on providing services to vulnerable young people in Bolivia, and part of that project is funded by Irish Aid. None of the resources that go to that project are used for advocacy-----
Well, we have. We are questioning the IFPA, we are in the course of asking questions of them. I also want to say that the witness or his colleague stated earlier that the women who attended undercover were not pregnant. However, I want to clarify that some of them had attended earlier when they were pregnant and they got that advice; that was why they were so concerned and went back to do the undercover. The witness also said that it was completely underhand and, I do not know what word was used to describe it, but I am saying that the witnesses have carried out the same kind of covert questioning themselves so they cannot have standards for one and not for the other. Just to clarify-----
No, to clarify that. The witness stated earlier that the women, with all due respect, the women who attended undercover were not pregnant. They were not at the time but some of them had, at least two or three, been pregnant. I am also concerned about, and I tried to interject on a point of order earlier, the witness stating earlier that the gardaí were embarrassed by the investigation. I know that if I complain to the gardaí or any citizen, it does not come back that they are embarrassed. We are encouraged every day of the week to make a report however trivial or frivolous or whatever, so I am wondering how he knows or got that insight from the investigating gardaí that they were embarrassed.
Please, I asked about this investigation several times on the Dáil floor and raised it with several Ministers and the previous Taoiseach. It went from an investigation down to an inquiry and then a HSE report. I think it is a pity that Deputy Fitzpatrick and Senator Mullen asked very pertinant questions today but they did not get answers. I am not getting them either. It is strange and the people that are watching can judge for themselves that any of the rest of the committee do not seem to be concerned about those issues only to say that we are undermining the work. We are here to do a job as Senator O'Sullivan said and do our best, that is all we can do.
I reaffirm my support for the Chairman and the work she is doing. I very much welcome the fact that she is an impartial, fair and balanced Chairman. It is imperative that the people who are home watching and listening to these proceedings would understand what is being done in a systematic and deliberate way to undermine the Chairman and all of us who are here, as Senator O'Sullivan rightly said, to find out information. There is a duty on everybody, irrespective of their viewpoint and from what vantage point they come, to engage with this process. As Senator Mullen knows quite well, when we held the hearings on the Protection of Life During Pregnancy Bill, I met him and the former Senator Walsh and individually went through with them a list of the people who were to come before us, and we put in place a process where non-members of the committee were involved in those hearings. Equally, it beggars belief that witnesses who refused to come in here on a Wednesday afternoon can appear on a television or radio programme and have their views articulated and announced when they cannot come before the Oireachtas. We are elected members. All of us have different viewpoints and that is fine.
The Senator will be aware that we met the former clerk to the Oireachtas Committee, Paul Kelly, to discuss the hearings on the Protection of Life During Pregnancy Bill and the Senator, along with the former Senator Jim Walsh, was a part of those.
I am trying to defend the integrity of the process of the Oireachtas committee system which works quite well. This committee works quite well. The point I am making is that there is a duty on those of us on all sides of the debate. I very much welcome that. This is a sensitive, complex matter; it is not black and white. Everybody should be in here debating and discussing it.
I thank Dr. Henchion and Mr. Behan for coming here this afternoon. I thank them for presentations and commend them on their work. I ask Dr. Henchion if it is fair to say that the values system and the mission statement of the Irish Family Planning Association, IFPA, is well known?
I thank Dr. Henchion for that.
Mr. Behan in his remarks, and if I am wrong on this, I apologise, said there was a shift in services and a shift in the way in which women were interacting or engaging with the IFPA. Will he elaborate on that?
My final question is to Dr. Henchion and if I misinterpreted what she said, I apologise. Will she elaborate on her point about having an abortion on socio-economic grounds? I believe she said it was not the way to go but I might be wrong on that. Will she elaborate on that view? I thank her again for being here.
Dr. Caitriona Henchion:
With regard to having an abortion for socio-economic grounds, what I am trying to say, and perhaps it is a little complex, is that in so far as the vast majority of abortions are occurring for socio-economic reasons, trying to draw up a list or some formula for deciding whether somebody should be entitled to an abortion on socio-economic grounds is not a practical thing to do and not a practical solution for addressing that issue. The only way to address that issue is by making access more open than that.
Mr. Niall Behan:
With respect to the way the services have changed or what we find are the needs of clients who have been using the services during the past 15 or 20 years, previously women came to us looking for phone numbers and addresses and where to go in the UK, they are coming to us now much more informed, having done an Internet search. They have an idea about where they want to go if they have made up their mind that they want to have an abortion. They may have a question. The other major shift we have seen is that the stigma is reducing, although it is still there and plays a huge part. The woman coming to us now will probably have told more people now than the woman who came to us 20 years ago about her intention either to have an abortion or if she is coming back for post-abortion care having had an abortion. We put this down to a breaking down of the stigma. We see more of our clients now presenting with someone. About 50% of the women who come to use our services present with either a friend or a relation. That is broken down roughly half and half between a male partner and either a mother, a friend, a sister or an aunt, where previously the women were mostly presenting alone.
Thank you, Mr. Behan.
I want to note apologies were received from Deputy Louise O'Reilly earlier, who is now here, and from Deputy Kelleher, who is dealing with other business in the Dáil.
I thank our witnesses, Dr. Henchion and Mr. Behan, for attending today. They have been very helpful to us in our deliberations. We are grateful to them for attending.
I propose we take 20-minute sos and resume at 4.15 in order that people can get a cup of coffee. We will resume in public session with out next witness at 4.15 p.m.