Dr. Patricia Lohr:

Thank you. I have a prepared statement and afterwards I will be happy to take any questions members may have.

My name is Patricia Lohr. I am the medical director of the British Pregnancy Advisory Service, BPAS. I trained in obstetrics and gynaecology at the Harbor-UCLA medical centre in Torrance, California. I followed this with a fellowship in family planning and contraception research and a masters degree in public health at the University of Pittsburgh. I am a fellow of the American Congress of Obstetricians and Gynecologists and of the US Society of Family Planning. I have an honorary fellowship form the UK Faculty of Sexual and Reproductive Healthcare. During my career, I have focused on the delivery of evidence based abortion care and family planning, including developing protocols, training doctors and nurses, providing services and conducting research. I am currently a member of the Royal College of Obstetricians and Gynaecologists, RCOG, abortion task force for which I am currently working on post-graduate curriculum development and a pathway for the care of women needing abortions who are medically complex. I am a founding member and the treasurer of the British Society of Abortion Care Providers which is an RCOG specialist society and currently sit on the National Institute for Health and Care Excellence, NICE, termination of pregnancy guideline committee which has been tasked with development a new evidence-based guideline for England. I was a member of the development group that wrote the last RCOG guidance on abortion care and have contributed to other national and international guidelines on contraception.

BPAS is a charity which was established in 1968 to provide not-for-profit abortion care that the National Health Service, NHS, at the time either could not or would not provide. Today, we provide contraception, pregnancy options counselling, abortion care and miscarriage management from more than 40 centres across England, Wales and Scotland. As part of our charitable remit, we also provide education on the causes and consequences of unwanted pregnancy and our nurses visit schools and colleges to provide information about contraception and fertility to young people to empower them with the knowledge to make their own reproductive decisions.

The majority of our services are provided under contract to the NHS, meaning the vast majority of women we see do not pay for their treatment. That now includes women from Northern Ireland, whose care is funded by the UK government and will be managed through a central booking service. The remainder are fee paying patients who overwhelmingly come from the Republic of Ireland. We provide care at or below cost to women from Ireland in recognition of the financial challenges they have already faced in reaching the UK and we have a policy of never turning any woman away based on her ability to pay.

While it is true that I am someone who believes strongly that abortion care is a fundamental part of women's reproductive health care, I am here today to provide this committee with factual information on the experience of Irish women who travel to the UK, how their abortion care is provided and the limitations of the current framework for providing the highest standard of care. As an organisation, we have no financial interest in Ireland changing its laws and will continue to provide not-for-profit services to Irish women if they cannot access abortion at home. In the UK, with the exception of Northern Ireland, a woman can access lawful abortion if she meets the terms of the Abortion Act 1967 and two doctors agree, in good faith, that she does so. Any abortion outside of that framework falls under the Offences Against the Person Act 1861 and carries the threat of life in prison for the woman and anyone who helps her. All abortions must be performed in NHS hospitals or at specifically licensed premises such as those run by BPAS.

The majority of abortions are performed under ground C, which stipulates that the pregnancy has not exceeded its 24th week and that the continuation of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman. A smaller number are performed under ground E, namely, that if the pregnancy continued the baby would be born with a serious mental or physical disability. The vast majority of abortions, 92% last year, were carried out at under 13 weeks' gestation and 81% were carried out at under ten weeks. This is in no small part due to the increasing availability of medical abortion, which can be offered at some of the earliest gestations. Medical abortion involves taking two medications, mifepristone and misoprostol, ideally 24 to 48 hours apart for maximum efficacy. Medical abortions account for more than 60% of the total number of abortions performed, although this method becomes less acceptable to women as gestational age advances.

Small numbers of abortions are performed after 20 weeks' gestation and account for approximately 1% of the total number of abortions performed. Some of these will be for reasons of foetal anomaly which are not detected until the scan at 20 weeks. Others will involve late detection of pregnancy, sometimes as a result of contraceptive use which has disturbed bleeding patterns, so that a missed period is not interpreted as a potential marker of pregnancy. While teenage pregnancies have declined dramatically over the past decade, a younger woman with an unwanted pregnancy is proportionately more likely to need a later abortion. This may be because a pregnancy was not suspected or because she has felt unable to confide in anyone about her circumstances.

In terms of the overall picture of abortion within the UK, the rate is stable at around 16 per 1,000 women. This rate is largely unchanged since the late 1990s. The age profile at which women have abortions is changing, however. The teenage pregnancy rate has decreased dramatically and more older women are requesting abortion care. At BPAS, we see more women over the age of 35 requesting abortion than women under 20. It is estimated that one in three women will need an abortion in their lifetimes and that one in five pregnancies end in abortion.

The abortion rate in England and Wales is similar to that in other socially and economically comparable countries such as France and Sweden. The UK is not an outlier in regard to its abortion rate. There is, in any event, no evidence that laws influence the numbers of abortions. The respected Guttmacher Institute has shown, for example, that the rate of abortion in countries with highly restrictive abortion laws is comparable with that in countries with more liberal frameworks.

To address specifically the issue of women from Ireland needing abortion care, last year 3,625 women were recorded in the annual abortion statistics produced by the Department of Health in England as having given an Irish address when they presented for treatment.

Over the past ten years, the number of women giving Irish addresses has fallen from 4,600 in 2008. This decline may be underpinned by a number of factors, including better access to contraceptive services and emergency contraception, increased access to abortion medication and increased awareness that free treatment can be obtained with a UK address. A paper published in the British Journal of Obstetrics and Gynaecologyin July reported that between January 2010 and December 2015, some 5,650 women from Ireland and Northern Ireland contacted one online provider alone to request medical termination of pregnancy.

BPAS has been providing abortion care to women from Ireland since 1968. There is little difference between the reasons women from Ireland present and the reasons women from the UK present; they are diverse and multifaceted. They may involve financial hardship, knowing one's family is complete, inadequate partner or family support, domestic violence or simply a woman feeling she is not in a position to care for a baby at that point in her life. While some abortions take place of pregnancies that were planned and wanted, such as those for foetal anomaly, the majority of the women we see were trying to avoid pregnancy when they conceived. In fact, the majority of women from Ireland we treat were using some form of contraception when they conceived. We undertook an analysis of 2,703 women from Ireland who were treated at BPAS over a four-year period and found the following: 3% were using a method such as an intrauterine contraceptive, implant or sterilisation; 29% were using injections, oral contraceptives, such as the pill, a patch or a ring; and almost 50% were using condoms, diaphragms or fertility awareness-based methods. Only 20% were not using any method at all at the time they conceived. Of Irish women who receive abortion care in the UK, 70% are married or with a partner, and nearly half have already had at least one previous birth, meaning they are already mothers. All this is in keeping with information we have for women from the UK seeking abortion.

What is different for Irish women? As previously noted, medical abortion now accounts for the majority of early terminations in the UK. Many women prefer it as it is akin to a natural miscarriage, they can avoid an anaesthetic and they can be at home when the pregnancy passes. In contrast, the majority of early abortions provided for Irish women are performed surgically - 71%, compared to 28% for women resident in England and Wales. This is because for financial and practical reasons, many women travelling from Ireland often aim to fly in and out of the UK within a day and, as medical abortion involves leaving the clinic after taking the second set of medication and going home to pass the pregnancy, it is not clinically optimal for this to happen on the way to the airport or the flight home. Effectively, this means that women from Ireland are in all practical senses denied a choice of abortion method.

Irish women also have abortions at slightly later gestations than women having abortions who are resident in England and Wales. The vast majority, 81%, of residents of England and Wales present between three and nine weeks' gestation, compared to 69% of women from the Republic of Ireland. At ten to 12 weeks' gestation, 11% of residents from England and Wales and 16% from the Republic of Ireland present. At the latest gestational bracket, 20 weeks or over, 2% of women resident in England or Wales present, compared to 3.2% of women resident in the Republic of Ireland. Nearly a third of abortions, 31%, for women from the Republic of Ireland are performed at ten weeks or over, compared to 20% for women resident in England and Wales. Abortion is an extremely safe procedure, but the earlier in pregnancy it is performed the better for women's physical and mental well-being. Reasons for later presentation include the time it takes to organise travel and make logistical arrangements, particularly for those with work and child care commitments.

All women who receive NHS-funded treatment at BPAS are entitled to contraception counselling. They can choose from the full range of methods available and, if they wish, can leave with the method of their choice. Provision of contraception at the time of abortion has several advantages - the woman is known not to be pregnant, and it confers immediate protection against pregnancy and, with regard to implants and intrauterine contraception, increases the likelihood she will receive the method compared to women who must return to undergo insertion at a later date. Irish women who attend BPAS are also offered contraceptive counselling, and the overwhelming majority take it up. However, because of the costs associated with receiving their chosen method, as well as the logistics of integrating contraception care with travel, in our analysis only 31% chose to receive their preferred method from BPAS. This is compared to 85% of women we see who are funded for their contraception care. This means that an important opportunity to enable women to make a choice about contraception and receive that method is lost. It is possible women visit their general practitioner or family planning clinic on return to Ireland and receive the method they have chosen, but we have no way of establishing this or following it up.

Regarding post-abortion care, all women undergoing an abortion at BPAS have access to a 24-hour telephone support line. While follow-up appointments are only provided to those women who want them, all women know they can contact the clinic which treated them and return for a check-up or discuss their concerns at any time. Women from the Republic of Ireland too can access the telephone support line, but if they have any concerns that need in-person care they will typically access local services, which can present its own problems in view of the stigma and secrecy that continues to surround travel for abortion.

Complications from abortion are uncommon, and serious complications are rare. In its paper, Best Practice in Comprehensive Abortion Care, the RCOG recommended that women be advised of the following risks. Failure occurs in one to two in 100 cases of either medical or surgical abortion. Fewer than two in 100 surgical abortions and approximately five in 100 medical abortions are incomplete and need some form of intervention in order to complete the procedure. The following complications may occur. Blood loss needing transfusion occurs in fewer than one in 1,000 cases in the first trimester, rising to approximately four in 1,000 at 20 weeks' gestation or more. Uterine rupture with second trimester medical abortion occurs in fewer than one in 1,000 cases. With surgical abortion there is a similar low risk of cervical trauma - fewer than one in 100 overall, but the risk is lower in the first trimester - or of uterine perforation, which occurs in approximately one to four cases per 1,000, and again the risk is lower in the first trimester. It is sometimes necessary to provide further treatment for complications such as a blood transfusion, laparoscopy, laparotomy and, very rarely, hysterectomy. An upper genital tract infection can occur after abortion, with varying degrees of severity, and is most likely associated with pre-existing infection.

Regarding the mental health impact of abortion, the risk of developing mental health problems is the same for a woman facing an unwanted pregnancy whether she has an abortion or goes on to have the baby. While most women will not require further counselling, post-abortion counselling is available to all women who have had an abortion at BPAS, either over the phone or in person. Needless to say, for women travelling from Ireland the option of in-person counselling at BPAS would be difficult, although this is available through some of the agencies in Ireland. We can advise women undergoing abortion for foetal anomaly on the transport of foetal remains for autopsy, burial or cremation. Women from Ireland must take the foetal remains home themselves and find a carrier that will accept the remains on board. If they want an autopsy or other testing for the foetal remains, this would be self-funded.

What can Ireland learn from the UK? If Ireland overhauls its abortion laws, which is certainly not for me to prejudge, it would do well to avoid some of the pitfalls and problems that the UK framework presents. The Abortion Act 1967 was passed at a time when abortion provision was almost entirely surgical and when all surgical procedures were riskier than they are today. Against this backdrop, it is unsurprising that politicians stipulated that all procedures should be carried out in an NHS hospital or in specific premises licensed by the Secretary of State for Health and that all such procedures should be performed by a doctor.

Few could have imagined in 1967 that early abortion could be safely provided using medication. Our laws have prevented the provision of early medical abortion in line with guidance from the World Health Organization, which recommends that women should be able to use misoprostol at home once lawfully prescribed. This means that women can time the passing of their pregnancy and do not have to risk bleeding or miscarriage on the way home, nor do they have to attend multiple appointments.

I spoke earlier about the number of women from Ireland using online abortion services and it may surprise the committee to know that women living in areas of the UK where funded, legal abortion is available are also turning online. Over a four month period more than 500 women in England, Wales and Scotland requested help from Women on Web, one of the online medication abortion providers. For some women, the multiple appointments, sometimes considerable distances from where they live, were an absolute impediment to accessing lawful care.

Our laws have also prevented the full development of nurse and midwife-led services that are now the standard in other areas of care like colposcopy. Nurses are lawfully able to provide surgical and medical miscarriage management using the same techniques as an early termination but are prohibited from providing that service to women needing an abortion. With regard to premises, there is no reason why early abortion, whether by vacuum aspiration or pills, could not be safely provided from a GP surgery but again our laws make that all but impossible.

Keeping abortion within the criminal law, as opposed to regulated by health care law like all other procedures, can be hugely stigmatising. Canada and parts of Australia have opted for the decriminalisation of abortion, regulating it through health care law and professional standards. There is no evidence that abortion is more widely used or indeed more available as a result. We do not need a criminal code to impose a time limit for example, but keeping the procedure outwith the criminal law and the subject of professional guidance and health care regulation means that lawful abortion care can be provided in accordance with the highest clinical standards and best practice. Ireland has the opportunity to create a humane abortion framework that is fit for the 21st century. I hope the information that I have provided to the committee is helpful for this discussion and I am happy to take any questions that members may have.