Five years after Ireland’s historic abortion referendum, access to care is still ‘patchy’

By Niamh Kennedy and Emily Blumenthal, CNN

(CNN) — In 2018, the Irish public voted overwhelmingly to repeal the country’s Eighth Amendment, overturning one of the strictest abortion bans in the European Union.

There were scenes of jubilation as the referendum result was announced, with many in Ireland seeing it as a historic step that would give women control over their own bodies.

But five years on, although abortion is free and legally available in Ireland up to 12 weeks of pregnancy – after that allowed only in exceptional circumstances, if there is a risk to the mother’s life or the fetus is not expected to survive – the abortion system is still far from where campaigners and charities would like it to be.

“The system is failing a certain number of women every year,” Ailbhe Smyth, a longtime women’s rights activist who campaigned for the repeal, told CNN.

One woman who experienced a failed medical abortion which pushed her to the edge of Ireland’s 12-week limit for terminations, told CNN that she felt unsupported by medical practitioners during the process and was made to feel ashamed.

“I felt like I had to say I had a miscarriage as opposed to an abortion, because there’s still stigma in the country,” said the woman, who requested that CNN call her Sarah due to her fears of the effects of stigma.

A report ordered by the Irish government, published last month, highlighted restrictive legal provisions and alarming gaps in the availability of abortion services, among other issues.

Three years on from the introduction of these services, access to abortion is “unequal” in Ireland, with women subjected to a “postcode lottery,” the review led by barrister Marie O’Shea said.

Rural parts of the country suffer particularly sparse coverage, the report found.

In nine of the Republic of Ireland’s 26 counties, there are fewer than five general practitioners (GPs) registered to provide services.

Orla O’Connor, director of the National Women’s Council of Ireland, told CNN the gaps in services impacted Ireland’s “more marginalized” women the most, listing homeless women, women in experiencing domestic abuse and disabled women as examples.

In response to CNN’s request for comment on the report’s findings and concerns over uneven access to abortion services, Ireland’s Department of Health described the referendum as “a landmark day” for reproductive rights in the country. “Since that day, significant strides have been made in the rollout of termination of pregnancy services for those who need them,” a statement from the press office said.

“The Minister for Health is committed to ensuring that any remaining barriers to services are identified and addressed, to give full effect to the historic decision of the Irish people.”

‘First step’

Despite the failings identified by the review, Thursday’s anniversary will hold a special place for Irish women at home and across the world.

For those at the forefront of the campaign, repealing the Eighth Amendment – which banned abortion in Ireland unless there was a “real and substantial risk” to the mother’s life – was very much the “first step” in making abortion part of healthcare for women, according to Smyth. She recalled thinking after the result was announced, “the hard work begins now.”

Although strike action and endorsements from high profile Irish figures had proved effective, Smyth recalls that it was testimonies from Irish women who traveled abroad for abortions which really galvanized the Irish public.

“It was women stepping forward and saying, 50 years ago, ‘I had an abortion in England, and I’ve never told anyone.’ ‘I’m aged 21. Last year, I had to go to England on my own.’

“It was these real stories of the distress for many women over decades of having had to do something that was important to them and having to do it in secrecy without help. That really, really struck people,” Smyth told CNN last week.

The call to reform Ireland’s repressive ban had intensified since 2012 following the death of a young woman named Savita Halappanavar, who died of complications after abortion was denied to her when she was miscarrying in a County Galway hospital, in western Ireland.

“It really brought into people’s consciousness that anybody could die simply by presenting at a hospital when they’re unwell and pregnant,” said Camilla Fitzsimons, an associate professor at the University of Maynooth who has researched the history of abortion in Ireland.

By the time the vote finally came around on May 25, 2018, there was a sense among Irish people that the abortion ban was “very wrong” and that if Irish society was ever to be equal, people would have “to put our trust in women and believe them when they say this is the best decision for me,” Smyth said.

Within four months of the referendum, Ireland’s president formally repealed the Eighth Amendment to the constitution. Irish lawmakers then passed the legislation that allows for terminations in the first 12 weeks of pregnancy.

Unequal access to care

But despite the changes heralded by the vote five years ago, the O’Shea review highlighted a number of obstacles to equal access to abortion services in Ireland.

Under current legislation, women must undergo a three-day waiting period after an initial consultation before gaining access to abortion medication, a requirement which medical practitioners have described as “patronizing,” according to the O’Shea review.

Sarah told CNN that, in her case, she found the three-day waiting period both “patronizing” and “upsetting.”

It’s a measure which medics and campaigners alike wish to scrap, especially in light of its impact on more vulnerable groups of women, who may find it difficult to attend two appointments.

One GP in the northwest of Ireland interviewed for the report highlighted the cost burden on lower income women, for example, stressing that “it’s not a free service if you have to spend 100 euro on petrol to get there and back” from appointments. During the Covid-19 pandemic, the Irish government allowed the first consultation to be done by phone, which report author Dr. Lorraine Grimes says improved but did not entirely solve the problem. Women still need to attend the second appointment in person for the procedure itself.

Dr. Mary Favier has played a huge part in organizing abortion services in GP clinics across Ireland. Although she acknowledges that coverage is “not perfect,” she is even more concerned about the situation in Irish maternity hospitals. At present, only 11 out of the 19 maternity facilities in the country are providing abortion services, the report states.

Favier says the expansion of services in maternity units has been held up by a controversial provision within the law which allows medical practitioners to refuse to provide abortion services on grounds of “conscientious objection.”

She chalks this up to “more conservative” attitudes among some Irish obstetricians and gynecologists, who she says for the most part did not actively participate in the “Repeal the 8th” campaign.

Although the proportion of conscientious objectors in Ireland’s health service is relatively small, Favier told CNN that they are concentrated in rural areas. And these tend to be places where there are fewer abortion providers already.

Favier also finds it “problematic” that abortion training, including on surgical procedures, has not been formally integrated into Irish medical schools’ curricula, and expressed support for the review’s recommendation that such training be “embedded” into teaching.

‘Tight’ time limit

Probably the greatest obstacle for Irish medical professionals, however, is a legal provision which criminalizes any individual who assists a pregnant person to obtain an abortion outside the confines of the law. This becomes especially relevant when considering the 12-week gestational limit embedded in the new legislation.

It is a limit which Grimes describes as “extremely tight.” This strict cut-off is also exacerbated by the three-day waiting period. If a woman is near the limit during the weekend or around a public holiday, she will have more difficulty accessing an appointment and may “time out” of care, Favier explains.

After 12 weeks it becomes “extremely difficult” to have an abortion in Ireland, according to Grimes. She highlights that in the case of a fatal fetal abnormality, for example, two doctors must certify that the baby would die within 28 days of being born for an abortion to be approved.

“That is practically impossible to do, it is really a huge ask,” Grimes said, noting that because abortion is still criminalized beyond the first 12 weeks, doctors tend to make more conservative decisions when dealing with complex cases.

Because the failed first abortion left her with only limited time for a second attempt before the 12-week limit, Sarah was left fearing her only options would be “to go to the UK or to continue with the pregnancy.”

Ultimately, a second procedure was carried out successfully at an Irish maternity hospital before the cut-off.

Sarah recounted the sense of anger she felt after one medical practitioner told her she was “lucky” to have made it within the limit.

“It shouldn’t be 12 weeks. What if it happened to somebody miscarrying? It just really resonated with me that mine was a choice. But if it wasn’t the choice, it would be very hard to hear words like that,” she said.

Against this backdrop, more than 200 Irish women still traveled to the UK for abortion procedures in 2021, according to UK health service statistics, although the O’Shea review notes that the “rate of abortion travel has declined substantially.”

“We do need to acknowledge that any instance where a woman has to leave her country to access full reproductive health care is a failure of the health system,” Grimes stressed.

Campaigners such as Smyth and O’Connor are now focusing their efforts on lobbying the Irish government to accept the recommendations within the O’Shea review. The Irish parliament’s health committee is set to review the findings before the summer.

In its statement to CNN, the Department of Health said the Health Service Executive, Ireland’s healthcare system, would work toward implementing the report’s operational recommendations. The parliamentary Joint Committee on Health would consider recommendations proposing legislative change, it added.

On Wednesday, the National Women’s Council launched an online campaign encouraging Irish people to write to their elected representative to call for “cross-party political commitment to reform,” according to a press release.

“Repealing the 8th didn’t mean abortion access only for some women and not others – the provision of abortion services needs to be consistent and equitable,” O’Connor stressed.

Sarah told CNN that she just wants women in Ireland to “feel that the decision they made is the right one” if they chose to have an abortion and that there is “no guilt or stigma attached” to having an abortion in 2023.

The-CNN-Wire
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