Emer Higgins: Balancing protections and timely abortion care

The Minister for Health, Jennifer Carl-MacNeill TD, who unfortunately is unavailable to be here this evening. She's attending a meeting of EU Health Ministers in Luxembourg. So just to assure the House that she would have been here otherwise, and I'm sure you'll appreciate, she just wasn't possible to be here this evening. I have spoken to the Minister and I will seek to reflect her views and indeed the views of the Department and the information provided to this Bill debate. I'd like to thank Sinn Féin and Deputy Cullnane for their work on this Bill and I welcome the opportunity to contribute to this important Bill. Like Minister Carl-MacNeill and many of us here in this House, we have heard the experiences of women who have availed of termination of pregnancy services and their honesty and their feedback are so appreciated and so valued. The Minister has also heard the views of clinicians and medical practitioners. I recognise that there is a broad spectrum of sincerely held opinion on the issue of termination of pregnancy and on the removal of the three-day wait and this House needs to facilitate an open and respectful debate to reflect both sides of the argument and all views. It's important, I believe, that all voices are heard, that we respect and we listen to each other. The Government is committed to ensuring that there is a safe and equitable access to termination of pregnancy services and I want to assure the House that this remains an ongoing priority. I'm also aware that the arguments borne against the removal of the mandatory three-day waiting period have been well aired in the public domain and at the outset one very important thing to do is to point out that the current model of care, which includes three-day wait, is safe and is effective. There are some very practical and operational considerations and challenges involved in abolishing the three-day wait. These are not insurmountable. However, I do have a responsibility to the House to be frank and to set them out and I believe it's critical that when we are required to vote we do so on the basis that we are making an informed choice and so I will set out some of the implications of this Bill. I understand the reasons behind the three-day wait and the reluctance and concerns of those who oppose its removal. I am aware that it was included in the 2018 Act, the outline of which was published as part of the information campaign on the referendum itself, and it allows individuals to consider their decisions carefully and avoid feeling rushed and avoid feeling pressured. It was intended to act as a legal safeguard demonstrating the serious and irreversible nature of the decision. From an operational perspective, the waiting period provides a structured and predictable pathway for both service users and providers. The HSE advises that the current model of care is, as I have said, safe and effective and that, as it stands, the model of care for termination of pregnancy services, the national clinical guidelines, service configuration and public information materials all centre around the requirement for a three-day wait. The provisions of services would therefore have to be fundamentally reconfigured if this Bill were to pass and it would therefore require careful consideration and planning. The removal of the statutory waiting period would have implications for the current model of care, the national clinical guidelines, service configuration and public information, as I have said. Clarification would be required regarding whether assessment and treatment could occur during the same visit, whether same-day treatment would be expected or simply permitted, and whether any reflection period would remain available at the request of the service user. The existing service model is based on separate stages of assessment of certification and of treatment and any move towards a more flexible or same-day pathway would necessitate changes to clinic scheduling, workforce deployment, patient flow arrangements and administrative processes. Consideration would also need to be given to the potential impact on service demand and capacity, particularly if there is an increase in requests for treatment on the day of assessment. As I said, these are not insurmountable. It is also important to point out that some of the logistical difficulties or burdens associated with the three-day wait have been alleviated by the introduction of the blended model of care for termination of pregnancy services in the community. This model, as people may be aware, was first introduced in response to the COVID pandemic and has been approved as the enduring model of care. Under this approach, it is possible for one of the two consultations—it's usually the first—required for termination in early pregnancy to take place remotely. On the other hand, it is necessary to recognise that mandatory waiting periods represent a departure from the norm when it comes to health. In most areas of healthcare, informed consent is based on a patient's capacity, on understanding and on voluntary decision-making rather than a prescribed waiting period. This debate provides us with the opportunity to reflect on whether that is necessary or, indeed, whether it is appropriate to attain such a requirement here in Ireland. I am aware that there are many who continue to view it as a necessary protection that provides women with a valued opportunity for reflection and consideration before treatment proceeds. Some will point to the gap in the numbers between those presenting for a first appointment and those proceeding to terminate the pregnancy, and they will argue that the provision is indeed saving lives. It is worth mentioning that the figures quoted in this respect are not collated for or, I believe, a reflection of evaluating the effectiveness of the three-day wait. They are simply claims for payment from community providers which are subject to review and change. There are many reasons why a woman may not return for a second appointment with a community provider. Firstly, she may be over the nine-week pregnancy mark and therefore be transferred into the hospital system. She may not have been pregnant at all, she may miscarry or she may travel abroad for care. Undoubtedly, there is a proportion of women who are changing their mind, although many studies, such as that of the Irish Family Planning Association, would suggest that that figure is actually quite small. It would be important to ensure any proposed amendment to the current legislation makes provision for the retention of a reflection period should a woman wish to avail of it. It is important to emphasise that women can continue to change their minds if they so wish. The lack of a mandatory reflection period could not mean a woman cannot change her mind. She is perfectly at liberty, after discussing the matter with her doctor, to decide not to proceed with the termination. The decision is hers and hers alone. Moreover, there are supports available to assist her in making that decision should she wish to avail of them. The HSE-funded MyOptions offers non-directive counselling and information for people experiencing an unplanned pregnancy. MyOptions is staffed by professionally trained counsellors who are experienced in providing support to women who are experiencing an unplanned pregnancy. The ethos of that service is client-centred and counsellors take their lead from the person contacting them for information and support. More fundamentally, we must acknowledge the difficulties that the mandatory waiting period can present for some women. It may in some circumstances create an unnecessary delay once a clear and informed decision has been made. Some women have said that it creates practical challenges in relation to travel, childcare, employment or other personal circumstances. Moreover, the additional appointments and administrative process can push patients past gestational limits, and this can pose particularly difficult for vulnerable groups and individuals. The unplanned abortion care study, commissioned as part of the review of the Health Act, explored the experiences of individuals accessing abortion services under section 12 of the Act. The findings indicate that the mandatory three-day waiting period was a recurring feature of discussions across the majority of interviews conducted. Participants expressed a range of views regarding its value and its impact. While some regarded it as a procedural requirement that had to be navigated, others viewed it as a barrier or a deterrent to accessing care. Very few participants considered the waiting period to have been beneficial to their own decision-making process, although some acknowledged that other women might value additional time for reflection. Internationally, the landscape has also shifted somewhat away from mandatory waiting periods. Health bodies such as the United Nations and the World Health Organization take a clear and evidence-based position on mandatory waiting periods for termination of pregnancy. The WHO, in its 2022 abortion care guideline, explicitly recommends against mandatory waiting periods, arguing that research shows that such delays offer no medical benefit and instead only restrict access to care and undermine service provision. These concerns are echoed by the Human Rights bodies within the United Nations. In addition, while reflection periods were a feature of the legislative regime in many European countries at the time of the introduction of the 2018 Act, a number of jurisdictions, including Spain, Netherlands and Luxembourg, have since removed them, reflecting a broader trend towards reliance on standard, informed consent processes. In conclusion, I would like to once again thank Sinn Féin for introducing this PMB. It is important that we, as legislators, provide a forum to debate these issues. The requirement for a mandatory waiting period is primarily policy choice, and we need to consistently look at our policies. This Bill provides us with an opportunity to reflect on the operation of the three-day wait. Those who support the passage of the Bill will point to the significant burdens enforced delays can cause, while those who oppose it will argue that the wait period is not a barrier but a protection against rushing into a choice that someone may later regret. The key challenge now in coming to a decision on the Bill is to find the appropriate balance between protective measures and compassionate and timely access to healthcare. If I can, I would like to conclude my remarks by making it clear that, should this PMB pass second stage, there would be full access to appropriate legal and drafting expertise to ensure that there are no unintended consequences and that the legislation would be as robust as possible if it passes. I look forward to construction.