Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697750692998.pdf (Ireland)
Oireachtas Library & Research Service | L&RS Note 1 L&RS Note Sexual and Reproductive Health and Rights (SRHR): A framework for the introduction of abortion services in Ireland Dr. Ann Nolan, Senior Parliamentary Researcher (Social Science) Abstract This L&RS Note will commence with a chronological summary of the abortion debate in Ireland and review the causes and outcomes of crisis pregnancy including updated statistics on abortions obtained inside and outside the State.
It will examine Ireland’s policy framework for sexual and reproductive health and rights (SRHR) in the context of the global policy architecture that has influenced the development of national policy.

Finally, it will review current provision for a comprehensive package of sexual and reproductive health services within the State with a particular focus on the services that provide an entry point for prevention and support of crisis pregnancies.
2 October 2018 2018 Oireachtas Library & Research Service | Sexual and Reproductive Health and Rights 2 Contents 1.

Introduction .............................................................................................................................. 4 2.

Summary overview of abortion in Ireland ................................................................................. 5 3.
The Domestic Policy Context ................................................................................................... 6 3.1 Characteristics of crisis pregnancy in Ireland ..................................................................... 6 3.2 Causes of crisis pregnancy in Ireland ................................................................................. 6 3.3 Reasons why people do not use contraception/contraception failure in Ireland .................. 7 3.4 Outcomes of crisis pregnancy ............................................................................................ 7 3.5 Abortions in Ireland ............................................................................................................ 8 Ireland’s relationship with the global policy architecture for sexual and reproductive health and 4. rights ............................................................................................................................................. 11 4.1 The International Conference on Population and Development, 1994 .............................. 11 4.2 Human rights treaties ....................................................................................................... 12 5.
What are sexual and reproductive health and rights (SRHR)?

............................................... 15 6.
Abortion as part of an integrated programme of sexual and reproductive health and rights (SRHR) in Ireland .......................................................................................................................... 18 6.1 Crisis pregnancy counselling services in Ireland .................................................................. 18 6.2 School-based relationships and sexuality education (RSE) ................................................. 18 6.3 Access to contraception in Ireland ....................................................................................... 20 6.4 Other services................................................................................................................. 22 6.4.1 Sexual Assault Treatment Units (SATU) ....................................................................... 22 6.4.2 Reproductive healthcare services: detection of foetal abnormalities ............................. 22 7.
Key factors in the successful implementation of abortion services ......................................... 23 8.

Conclusion ............................................................................................................................. 24 Oireachtas Library & Research Service | L&RS Note 3 Legal Disclaimer No liability is accepted to any person arising out of any reliance on the contents of this paper.

Nothing herein constitutes professional advice of any kind.
This document contains a general summary of developments and is not complete or definitive.

It has been prepared for distribution to Members to aid them in their parliamentary duties.

Some papers, such as Bill Digests are prepared at very short notice.

They are produced in the time available between the publication of a Bill and its scheduling for second stage debate.

Authors are available to discuss the contents of these papers with Members and their staff but not with members of the general public.
© Houses of the Oireachtas 2018 Oireachtas Library & Research Service | Sexual and Reproductive Health and Rights 4 1.

Introduction Abortion is a contested policy domain in every jurisdiction with debates rooted in ideological positions that emphasise the rights of the unborn and the rights of the mother to exert control over her own body.
This L&RS Note will commence with a summary overview of the abortion debate in Ireland and review the drivers and outcomes of crisis pregnancy including updated statistics on abortions obtained outside the State.

Ireland’s commitment to the provision of a comprehensive programme of sexual and reproductive health and rights (SRHR) forms part of an international Programme of Action, which was first adopted by Ireland at the International Conference on Population and Development (ICPD) in 1994.
As such, this Note will examine Ireland’s policy framework for SRHR within this context.

It will review current provision for a comprehensive package of sexual and reproductive health services within the State with a particular focus on the services that provide an entry point for prevention and support of crisis pregnancy.

Oireachtas Library & Research Service | L&RS Note 5 2.
Summary overview of abortion in Ireland Ireland was quite unique in that up to the 1980s, the Offences against the Person Act, 1861, which criminalised abortion, prompted little debate and went virtually unchallenged for over a century.

International liberalisation of the laws governing abortion - particularly the Roe vs Wade Supreme Court judgement in the United States1 - prompted concerns among conservative groups and calls for a pro-life amendment to the Constitution of Ireland.
Described as one of the most bitter and divisive campaigns in the history of the State,2 the Eighth Amendment of the Constitution (Article 40.3.3) was carried by a 66.45% majority in 1983 enshrining in law the equal right to life of the mother and the unborn child.

In less than a decade, the Supreme Court in the X Case in which a 14-year-old girl who was pregnant as a result of rape, ruled that she faced a real and substantial risk to her life due to the threat of suicide.
As such, Ms X was entitled to an abortion in Ireland under the provisions of Article 40.3.3, which states: The State acknowledges the right to life of the unborn and, with due regard to the equal right to life of the mother, guarantees in its laws to respect, and, as far as practicable, by its laws to defend and vindicate that right.3 The decision of the Supreme Court in the X case prompted another two referenda.
However, since the referendum in 1983, there have been five abortion referenda, the last on 25th May 2018 in which the electorate voted by a 66.4% majority to repeal the Eighth Amendment.
In 2010, the case of A, B, and C v Ireland4 was heard at the European Court of Human Rights where it was unanimously agreed that Ireland's failure to implement the existing constitutional right to a lawful abortion when a woman's life is at risk violated Applicant C's rights under Article 8 of the European Convention on Human Rights.
The Protection of Life During Pregnancy Act, 2013 (see here for Bill Digest) legislates for the 1992 judgment of the Supreme Court in the X case and the 2010 ruling of the European Court of Human Rights in the case of A, B and C vs Ireland.

The Act provides for lawful access to abortion where a pregnant woman’s life is at risk, however, termination of pregnancy remains otherwise criminalised in Ireland.
With the exception of Malta, most countries in the European Union permit abortion on demand during the first trimester.

After the first trimester, abortion is legal under a range of circumstances including, i) the risk to a woman’s life or health; ii) fatal foetal abnormalities or serious impairment; and iii) in specific situations including rape or a girl’s age.
For further information, see the L&RS Bill Digest on the Thirty-sixth Amendment of the Constitution Bill, 2018 1 Roe v Wade was a landmark case heard by the United States Supreme Court in 1973, which affirmed the constitutional right to access safe and legal abortion.

2 Tom Hesketh, The Second Partitioning of Ireland?

: The Abortion Referendum (Dublin: Brandsma Books, 1990).

3 Bunreacht Na HÉireann = Constitution of Ireland.

Article 40.3.3.

Dublin :Oifig an tSoláthair, 1945.

Print.

APA.

Ireland.


(1945).

4 European Court of Human Rights, CASE OF A, B AND C v. IRELAND (Application no.

25579/05), JUDGMENT STRASBOURG 16 December 2010 Oireachtas Library & Research Service | Sexual and Reproductive Health and Rights 6 3.
The Domestic Policy Context Crisis pregnancy is defined in by the Crisis Pregnancy Agency (Establishment) Order, 2001 as: …a pregnancy which is neither planned nor desired by the woman concerned and which represents a personal crisis for her.5 This definition includes the experiences of women for whom a planned pregnancy may develop into a crisis over time due to a change in circumstances.6 It is estimated that 44% of all pregnancies worldwide are unintended and up to 56% of unintended pregnancies end in abortion.7 3.1 Characteristics of Crisis Pregnancy in Ireland In excess of 65% of women and men who have experienced a crisis pregnancy in Ireland report that they were in a steady relationship, cohabiting, engaged or married at the time.8 One in three was not in a steady relationship and one in twenty was in other kinds of relationships including extra-marital relationships.
Sexually active women in Ireland in all fertile age categories are at risk of developing a crisis pregnancy but some groups are more at risk than others including younger women between the age of 18-25 years and women with a pre-Leaving Certificate education.9 Up to 44% of pregnancies among women aged 18-25 are unplanned.10 Young women whose sexual debut11 is before the age of 17 are less likely than women who delay first sexual experiences to use contraception: they are also 70% more likely to experience a crisis pregnancy and three times more likely to experience an abortion in later life.12 The prevalence of crisis pregnancy among women in older age categories (36-45) is lower than in younger women but between 2003 and 2010 there was an increase in older married women reporting a crisis pregnancy which may have been related to the banking crisis.13 The characteristics of crisis pregnancy in Ireland reflect wider international trends: worldwide socio-economic status and higher educational attainment improve women’s ability to access information and services and to exert control over their sexual and reproductive lives.14 15 Higher education is generally associated with improved access to health care, fewer births and better sexual health outcomes overall.16 3.2 Causes of Crisis Pregnancy in Ireland While contraceptive failure is a factor in crisis pregnancy, up to 50% of women who report experiencing a crisis pregnancy in Ireland in 2010 did not use contraception at the time of 5 Irish Statute Book, “Crisis Pregnancy Agency (Establishment) Order.,” Pub.
L. No.

S.I.

No.

446/2001 (2001).

6 Irish Statute Book, “Crisis Pregnancy Agency (Establishment) Order.,” Pub.

L. No.

S.I.

No.

446/2001 (2001).

7 Susheela Singh et al., “Abortion Worldwide: Uneven Progress Unequal Access” (Guttmacher Institute, 2017).

2017: 5 8 HSE Sexual Health and Crisis Pregnancy Programme, “Sexual Health in Ireland: What Do We Know?"

(Dublin: Health Service Executive, June 2018: 24).


9 Mayock, P. and Byrne, T., “A Study of Sexual Health Issues, Attitudes and Behaviours: The View of Early School Leavers CPAR Report No.8.

2004, Crisis Pregnancy Agency: Dublin.” (Dubllin: Crisis Pregnancy Agency, n.d.).

10 HSE Sexual Health and Crisis Pregnancy Programme, “Sexual Health in Ireland: What Do We Know?”pp24 11 First sexual experience.

12 HSE Sexual Health and Crisis Pregnancy Programme.
2018 13 HSE Sexual Health and Crisis Pregnancy Programme.

2018 14 Jejeebhoy S. Women’s education, autonomy and reproductive behavior: experience from developing countries.

New York, NY: Oxford University Press, 1995.

15 United Nations Development Programme, “Human Development Report 2016: Human Development for Everyone” (New York, 2016).

16 Güneş PM.

The role of maternal education in child health: Evidence from a compulsory schooling law.
Econ Educ Rev 2015; 47: 1–16 Oireachtas Library & Research Service | L&RS Note 7 conception with primary reasons being that ‘sex was not planned’ (32%); that they ‘took a chance’ (30%) or that alcohol or other drugs were used at the point of conception (20%).
17 This latter reason for not using contraception corresponds with international research, which points to clear links between substance use, sexual risk taking and early sexual initiation.18 Almost half (47%) of those surveyed in 2010 who did not use contraception reported that they did not believe that they were at risk of becoming pregnant at the time.
This finding is linked to other research that shows that the proportion of adults who correctly identify when a woman is fertile is 50%.19 The Sexual Health and Crisis Pregnancy programme emphasises the importance of sexual knowledge and understanding of fertility as central to effective contraceptive practice.

20 3.3 Reasons why people do not use contraception/contraception failure in Ireland Most unplanned pregnancies result from inconsistent or incorrect contraceptive use.
The proportion of men and women who consistently use contraception has decreased from 83% in 2003 to 78% in 2010.

21 Local accessibility can be a barrier to access and cost is a factor affecting particularly younger age groups.
Embarrassment and stigma are also barriers to access with negative attitudes towards women carrying condoms while not in a relationship a persistent disincentive.22 Non-use of contraception is a factor in half of all reported crisis pregnancies.23 3.4 Outcomes of Crisis Pregnancy Most crisis pregnancies are resolved by the birth of a baby: up to 75% of women and 66% of men who experience a crisis pregnancy in Ireland chose to parent.
24 However, only 1% of women and men opted for adoption following their most recent experience of crisis pregnancy.25 There is a significant decline in the number of children placed for adoption in Ireland in the last 30 years from 1,005 in 1976 to 35 in 2016.

26 Research conducted in 2010 found that 32% of men and 24% of women reported that their most recent experience of crisis pregnancy ended in abortion.
27 There has been a 54% decrease in the number of women travelling from the Republic of Ireland to the UK for an abortion between 2001 and 2017.

In 2017, 3,092 women living in Ireland had an abortion in the UK which is less than half the number in 2001 and a further 5% decline from 2016 (See Figure 1).
The number of women accessing abortion in the UK who are not ordinarily resident there is the lowest in any year since 1969.28 17 McBride, O., Morgan, K. and McGee, H., “Irish Contraception and Crisis Pregnancy Study 2010: A Survey of the General Population Crisis Pregnancy Programme Report 24.” (Dublin: HSE Crisis Pregnancy Programme, 2012).

18 Jackson C, Sweeting H, Haw S. Clustering of substance use and sexual risk behaviour in adolescence: analysis of two cohort studies.

BMJ Open.
BMJ Open.

2012;2 55; Wiefferink CH, Peters L, Hoekstra F, Ten Dam G, Buijs GJ, Paulussen TG.

Clustering of health-related behaviours and their determinants: possible consequences for school health interventions.

Prev Sci.

2006;7:127–49; Spriggs Madkour A, Farhat T, Tucker Halpern C, Godeau E, Nic Gabhainn S. Early adolescent sexual initiation as a problem behaviour: a comparative study of five nations.

J Adolesc Health.
J Adolesc Health.

2010;47:389–98.57; Connell C, Gilreath T, Hansen N. A multiprocess latent class analysis of the co-occurance of substance use and sexual risk behaviour among adolescents.

J Stud Alcohol Drugs.

2009;70:943–51.

19 HSE Sexual Health and Crisis Pregnancy Programme, “Sexual Health in Ireland: What Do We Know?” 2018 20 HSE Sexual Health and Crisis Pregnancy Programme, “Sexual Health in Ireland: What Do We Know?” 2018 21 Ibid.
pp36 22 McBride, O., Morgan, K. and McGee, H., Irish Contraception and Crisis Pregnancy Study 2010: A Survey of the General Population, Crisis Pregnancy Programme Report 24.

2012, HSE Crisis Pregnancy Programme: Dublin 23 Ibid 24 HSE Sexual Health and Crisis Pregnancy Programme.2018 25 Ibid 26 The Adoption Authority of Ireland, “The Adoption Authority of Ireland Annual Report 2016.” (Dublin: The Adoption Authority of Ireland, 2017).
27 HSE Sexual Health and Crisis Pregnancy Programme, “Sexual Health in Ireland: What Do We Know?” 28 Department of Health and Social Care, “Abortion Statistics, England and Wales: 2017: Summary Information from the Abortion Notification Forms Returned to the Chief Medical Officers of England and Wales.,” June 2018.pp19 Oireachtas Library & Research Service | Sexual and Reproductive Health and Rights 8 3.5 Abortions in Ireland Abortion is legally available in Ireland in a limited set of circumstances where there is a substantial risk to the life of the mother, as provider by the Protection of Life during Pregnancy Act 2013 29 The Department of Health publishes the number of abortions in Ireland on an annual basis.
There were 26 abortions obtained in both 2014 and 2015, and 25 in 2016, the majority of which were due to a risk to the life of the mother.
30 Figure 1: Number of Abortions for Residents of Northern Ireland and the Republic of Ireland 1970-201731 (Source: United Kingdom Department of Health and Social Care, 2018) In 2017, the largest proportion of women who accessed abortion services in the UK and provided an address in the Republic of Ireland were in the 20-29 age category (46%), while 64 (2%) abortions were obtained by girls age 17 years and younger (see Figure 2).
Figure 4 illustrates the number of weeks gestation at which an abortion was obtained in England and Wales by women providing an address in the Republic of Ireland in 2017.

The vast majority, 2,023 (65%) were at 3-9 weeks gestation; followed by a further 550 (18%) terminations at 10-12 weeks gestation; 401 (13%) and 118 (4%) at 13 to 19 weeks, and 20 weeks and over respectively.

Eighteen per cent (n=557) of women travelling from Ireland obtained a repeat abortion in England and Wales in 2017.
Twenty-five per cent of those (n=725) were single with no partner and 47% (n=1393) were single with a partner.

Those who were married or in a civil partnership accounted for 21% (n=617) of women and 77 (3%) were separated, widowed or divorced.32 29 Protection of Life During Pregnancy Act 2013.

2013, Irish Statute Book: Ireland.

30 Department of Health, Notifications in Accordance with Section 20 of the Protection of Life During Pregnancy Act 2013: Annual Report 2014.

2015, Department of Health: Dublin.


72.

Department of Health, Notifications in Accordance with Section 20 of the Protection of Life During Pregnancy Act 2013: Annual Report 2015.

2016, Department of Health: Dublin.

31 Department of Health and Social Care.

June 2018.pp20 32 Department of Health and Social Care.

“Tables: Abortion Statistics 2017.” June, 2018.
Oireachtas Library & Research Service | L&RS Note 9 Figure 2: Abortions by age category in England and Wales by women providing an address in the Republic of Ireland 2017 8% 2% 5% 39% 46% under 17 18-19 20-29 30-39 40 & over Figure 3: Abortion by number of weeks gestation in England and Wales by women providing an address in the Republic of Ireland 2017 4% 13% 18% 65% 3-9 weeks 10-12 weeks 13-19 weeks 20 weeks & over (Source: Compiled by the L&RS from data provided by the United Kingdom Department of Health and Social Care, 2018) The Ministry of Health in the Netherlands reported that 34 women gave Irish addresses to abortion clinics in the Netherlands in 2015 pointing to a significant decline since 2006 when there were 461 cases.
33 This data does not appear to have been updated.
A study by Aiken et al demonstrated that 1,642 abortion pill packages were sent to Ireland in the 3- year period between 2010 and 2012 by a single provider.34 Between January 2010 and December 2016 the number of women accessing abortion pills from one online provided tripled from 548 consultations in 2010 to 1,748 in 2016.35 Uptake of at‐home medical termination of pregnancy 33 Ministerie van Volksgezondheid, Welzijn en Sport, “Women Providing Irish Addresses in Dutch Abortion Clinics Since 2010, Personal Communication to M. O’Brien by Email, 30 January 2017 in Sexual Health in Ireland: What Do We Know?,” 2018.
34 Aiken ARA, Gomperts R, Trussell J.

Experiences and characteristics of women seeking and completing at‐home medical termination of pregnancy through online telemedicine in Ireland and Northern Ireland: a population‐based analysis.

BJOG 2017; 124:1208–1215.


35 Ibid Oireachtas Library & Research Service | Sexual and Reproductive Health and Rights 10 may account for the exponential decline in the number of women accessing termination of pregnancy procedures in the UK but other factors – including the possibility of more effective family planning – may also be at play.
However, it is currently unclear if there is an association between the decline in the number of women accessing abortion in the UK and the increase in the number of women accessing abortifacients36 online.

36 A drug that prompts abortion of an embryo or foetus.

Oireachtas Library & Research Service | L&RS Note 11 4.
Ireland’s relationship with the global policy architecture for sexual and reproductive health and rights 4.1 The International Conference on Population and Development, 1994 The International Conference on Population and Development (ICPD) was held in Cairo in September 1994 and was the first global agreement for sexual and reproductive health and rights.
The ICPD defined reproductive healthcare in terms of maternal health, family planning, sex education, fertility treatment, sexually transmitted infections including HIV, and safe abortion in countries where it is permitted by law.

One hundred and seventy-nine countries, including Ireland, adopted a 20-year Programme of Action that was extended in 2010.
This has been an important international agreement in terms of Ireland’s position on abortion for two reasons:  The ICPD stipulated in paragraph 7.24 that Governments should take appropriate steps to help women avoid abortion;  Paragraph 8.25 stipulated that abortion should not be promoted as a method of family planning and changes related to abortion within the health system can only be determined at the national or local level according to the national legislative process.37 Ireland’s statement to the UN Commission on Population and Development in April 2011 reconfirmed a commitment to the ICPD but emphasised Ireland’s alignment with the provisions of paragraph 8.25.
The statement defined the position with regard to sexual and reproductive health rights and services: …our position [is] that sexual and reproductive health and rights (SRHR) and sexual and reproductive health services (SRHS) do not include an intrinsic right to abortion…38 In October 2012, the Department of Foreign Affairs and Trade in collaboration with the Department of Health agreed negotiating guidelines for sexual and reproductive health and rights at international levels.
The guidelines indicate that Ireland can accept factual references to unsafe abortion as a driver of maternal mortality in developing countries but confirms a general preference for inclusion of other main drivers of maternal mortality.39 The underlying reasons why women choose unsafe abortions including lack of access to reproductive health services like contraception, information or low levels of gender inequality are also emphasised by Ireland in negotiations.
International agreements that urge governments to ensure appropriate responses to the consequences of abortion are also acceptable.

This includes humane treatment and the provision of counselling to women who have undergone abortion.
Ireland may also accept references to the appropriate training of health service providers to ensure that abortion is safe and accessible.40 It is estimated that up to 25 million unsafe abortions take place worldwide on an annual basis.41 The Guttmacher Institute, a US-based research and policy organisation committed to advancing 37 United Nations Population Fund, “International Conference on Population and Development (ICPD)” (Cairo, 1994).
38 Department of Foreign Affairs and Trade/Department of Health, “Negotiating Guidelines on SRHR Issues,” Updated October, 2012 [in personal email to the author on request, dated 12th June 2018] 39 Department of Foreign Affairs and Trade/Department of Health.

October 2012.

40 Department of Foreign Affairs and Trade/Department of Health.

October 2012.
October 2012.

41 Ann M Starrs et al., “Accelerate Progress—Sexual and Reproductive Health and Rights for All: Report of the Guttmacher– Lancet Commission,” The Lancet 391, no.

10140 (June 2018): 2642–92, https://doi.org/10.1016/S0140-6736(18)30293-9.
Oireachtas Library & Research Service | Sexual and Reproductive Health and Rights 12 sexual and reproductive health and rights (SRHR) globally, reports that unsafe abortions occur overwhelmingly in developing regions.42 However, Ireland’s international negotiations with regard to sexual and reproductive health and rights must oppose references that urge governments to provide access to safe abortion: …unless such references are contextualized by the phrase ‘where legal’ or ‘in line with national legislation’ (i.e.
in line with the principles contained in the ICPD).

This is a red line for Ireland.43 These provisions define the parameters of policy dialogue between Irish Aid – Ireland’s overseas development assistance programme - and bilateral partners in programme countries in Eastern and Southern Africa with regard to unsafe abortions.
Women in Southeast Asia and sub-Saharan Africa – where most of Irish Aid’s programme countries are located44 - experience the highest rate of maternal deaths (86% of global maternal deaths) and the majority of these deaths are due to complications during pregnancy, infections, and unsafe abortion.45 One World One Future, Ireland’s policy for international development (2013) emphasises a commitment to reduce maternal and infant mortality that is consistent with the ICPD Cairo Programme of Action, while “supporting safe motherhood and allowing women to control their own fertility within the context of national legislative frameworks.”46 This policy priority is embedded within the Sustainable Development Goals47 particularly Goal 5.6 that commits to reproductive health and rights in both developed and developing countries in accordance with the ICPD and the Beijing Platform for Action.
48 4.2 Human rights treaties An international human rights treaty is adopted by the international community through the United Nations General Assembly.

Each treaty sets out a range of human rights and obligations that are legally binding on States that have ratified them.

As indicated by Table 1, Ireland has ratified nine United Nations (UN) human rights treaties (for further information, see L&RS Note on International Law).
The Committees of five of these have expressed concern and criticised Ireland’s restrictive abortion laws.

49 50 51 52 These are committees of independent experts that monitor implementation of the core international human rights treaties.

UN treaty monitoring bodies, regional and national courts have given increasing attention to abortion including criminalisation of abortion, and the impact of restrictive legislation.
42 Susheela Singh et al., “Abortion Worldwide: Uneven Progress Unequal Access” (Guttmacher Institute, 2017).

2017: 5 43 Department of Foreign Affairs and Trade/Department of Health.

October 2012.

44 Irish Aid’s partner countries in sub-Saharan Africa are: Ethiopia; Malawi; Mozambique; Tanzania; Uganda; Zambia; Sierra Leone.

Vietnam is Ireland’s only partner n southeast Asia.
45 United Nations Millennium Development Goal Monitor: MDG 5, Improve Maternal Health http://www.mdgmonitor.org/mdg-5-improve- maternal-health/ [accessed 2.10.2018] 46 Irish Aid.

One World One Future: Ireland’s Policy for International Development.

(Dublin, 2013) pp22 47 The Sustainable Development Goals provide a blueprint for international development to address a range of issues including poverty, glo9bal health, injustice and climate change.
They result from inclusive consultations and negotiations between UN Member States, civil society and citizens around the world.

The final set of negotiations at the UN was co-facilitated by Ireland and Kenya.

48 This was a meeting of the Fourth World Conference on Women in September 1995 in Beijing, which resulted in a Beijing Declaration and Platform for Action, the most progressive blueprint ever for advancing women’s rights.
49 United Nations Committee against Torture, “Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment: Concluding Observations on the Second Periodic Report of Ireland*,” August 31, 2018.

50 Committee on the Rights of the Child, “Convention on the Rights of the Child: Concluding Observations on the Combined Third and Fourth Periodic Reports of Ireland” (United Nations, March 1, 2016).

51 Committee on the Rights of the Child.


52 Committee on the Elimination of Discrimination and against Women.
Oireachtas Library & Research Service | L&RS Note 13 Table 1: United Nations Human Rights Instruments: Ratification Status for Ireland53 Treaty Description Treaty Name Signature Date Ratification Date, Accession(a), Succession(d) Date CCPR-OP2- DP CAT-OP CEDAW CAT CED Convention against Torture and Other Cruel Inhuman or Degrading Treatment or Punishment Optional Protocol of the Convention against Torture International Covenant on Civil and Political Rights CCPR Second Optional Protocol to the International Covenant on Civil and Political Rights aiming to the abolition of the death penalty Convention for the Protection of All Persons from Enforced Disappearance Convention on the Elimination of All Forms of Discrimination against Women International Convention on the Elimination of All Forms of Racial Discrimination International Covenant on Economic, Social and Cultural Rights International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families Convention on the Rights of the Child Optional Protocol to the Convention on the Rights of the Child on the involvement of children in armed conflict Optional Protocol to the Convention on the Rights of the Child on the sale of children child prostitution and child pornography Convention on the Rights of Persons with Disabilities (Source: United Nations Human Rights Office of the High Commissioner) CERD CRPD CMW CESCR 28 Sep 1992 11 Apr 2002 02 Oct 2007 01 Oct 1973 29 Mar 2007 08 Dec 1989 18 Jun 1993 (a) 23 Dec 1985 (a) 21 Mar 1968 29 Dec 2000 01 Oct 1973 08 Dec 1989 30 Sep 1990 28 Sep 1992 CRC CRC-OP-AC 07 Sep 2000 18 Nov 2002 CRC-OP-SC 07 Sep 2000 30 Mar 2007 20 Mar 2018 The review of the Committee against Torture in 2013 and again in 2017 expressed concern with regard to the: …severe physical and mental anguish and distress experienced by women and girls regarding termination of pregnancy due to the State policies.54 The Human Rights Committee and the UN Committee on Economic, Social and Cultural Rights have each criticised Ireland's restrictive abortion laws.
In 2016, during the combined third and fourth periodic review of Ireland’s implementation of the UN Convention on the Rights of the Child, the Committee expressed concern about the Protection of Life during Pregnancy Act 2013, which allows for abortion only when there is a real and substantial risk to the life of the mother and otherwise criminalises abortion.55 The Committee also expressed concern about the ability of doctors to provide services in accordance with ‘objective medical practice’ and recommended that Ireland: 53 United Nations Human Rights Office of the High Commissioner, “Ratification Status by Country,” https://tbinternet.ohchr.org/_layouts/TreatyBodyExternal/Treaty.aspx?CountryID=83&Lang=EN, n.d., accessed September 19, 2018.
54 United Nations Committee against Torture, “Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment: Concluding Observations on the Second Periodic Report of Ireland*,” August 31, 2018.

55 Committee on the Rights of the Child, “Convention on the Rights of the Child: Concluding Observations on the Combined Third and Fourth Periodic Reports of Ireland” (United Nations, March 1, 2016).
Oireachtas Library & Research Service | Sexual and Reproductive Health and Rights 14 Decriminalize abortion in all circumstances and review its legislation with a view to ensuring access by children to safe abortion and post-abortion care services; and ensure that the views of the pregnant girl are always heard and respected in abortion decisions; Develop and implement a policy to protect the rights of pregnant teenagers, adolescent mothers and their children and combat discrimination against them.56 In its concluding observations on the combined sixth and seventh periodic reports of Ireland, the Committee on the Elimination of Discrimination against Women (CEDAW) referred specifically to Article 40.3.3 of the Constitution, which states that: The State acknowledges the right to life of the unborn and, with due regard to the equal right to life of the mother, guarantees in its laws to respect, and, as far as practicable, by its laws to defend and vindicate that right.57 The Committee urged the Irish State to amend article 40.3.3 and to ensure the provision of post- abortion health-care services for women “irrespective of whether they have undergone an illegal or legal abortion.”58 CEDAW expressed concern for women and girls compelled to travel outside the State to obtain abortion services especially those without means who may be forced to carry their pregnancies to full term or undertake unsafe abortion including poor women, asylum seekers, and migrant women and girls.59 56 Committee on the Rights of the Child.
57 Bunreacht Na HÉireann = Constitution of Ireland.

Article 40.3.3.

Dublin :Oifig an tSoláthair, 1945.

Print.

APA.

Ireland.

(1945).

58 Committee on the Elimination of Discrimination and against Women, “Committee on the Elimination of Discrimination against Women: Concluding Observations on the Combined Sixth and Seventh Periodic Reports of Ireland” (United Nations, March 9, 2017).

59 Committee on the Elimination of Discrimination and against Women.
Oireachtas Library & Research Service | L&RS Note 15 5.

What are sexual and reproductive health and rights (SRHR)?
SRHR are linked to each other: for example, sex education leads to improved sexual and reproductive health outcomes, including unintended or crisis pregnancy,60 while women who have experienced school-based sex education are less likely to obtain an abortion.61 62(See L&RS Spotlight on school-based relationships and sexuality education (RSE): lessons for policy and practice, for further details).
Table 2 illustrates the various components and requirements of sexual health, reproductive health, sexual rights and reproductive rights, while highlighting where safe abortion services are integrated within that pathway of care.

Within this framework, abortion services are integrated with contraceptive services, sexual knowledge and sex education services, STI and HIV prevention and treatment services, and wider reproduce health service provision.
The Lancet Commission on SRHR reported in June 2018 that changes to any single area are unlikely to be sufficient and emphasised that SRHR approaches tend to benefit from multipronged strategies.63 The need for a patient-centred clinical care pathway for termination of pregnancy as part of a comprehensive package of reproductive and sexual health services in Ireland was also emphasised by clinicians presenting to the Joint Committee on Health’s consideration of the development of clinical guidelines in light of the impending introduction of abortion services.64 Table 2: Components of sexual and reproductive health and rights65 What is sexual health?
“A state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity.

Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.
For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.”66 Sexual health implies that all people have access to: • counselling and care related to sexuality, sexual identity, and sexual relationships; • services for the prevention and management of sexually transmitted infections, including HIV/AIDS, and other diseases of the genitourinary system; • psychosexual counselling, and treatment for sexual dysfunction and disorders; • prevention and management of cancers of the reproductive system.
60 UNESCO, Emerging Evidence, Lessons and Practice in Comprehensive Sexuality Education: A Global Review (Paris: France, 2015); WHO.

Defining sexual health.

Report of a technical consultation on sexual health 28-31 January 2002.

Geneva: WHO; 2006 61 Pound P, Denford S, Shucksmith J, et al.

What is best practice in sex and relationship education?

A synthesis of evidence, including stakeholders’ views.

BMJ Open 2017;7:e014791.

doi: 10.1136/bmjopen-2016-014791.
Pp4 62 The evidence for sex education is neither unambiguous nor uncontested: a Cochrane Database Systematic Review published in 2016 reported that schools “may” be a good place in which to provide interventions that prevent HIV, sexually transmitted infections, and crisis pregnancy in adolescents but found little evidence that educational curriculum-based programmes alone are effective in improving sexual and reproductive health outcomes for adolescents 62 63 Ann M Starrs et al., “Accelerate Progress—Sexual and Reproductive Health and Rights for All: Report of the Guttmacher– Lancet Commission,” The Lancet 391, no.
10140 (June 2018): 2642–92, https://doi.org/10.1016/S0140-6736(18)30293-9.

64 Irish College of General Practitioners, “Opening Statement by the Irish College of General Practitioners to the Oireachtas Joint Committee on Health Relating to the Provision of Termination of Pregnancy Clinical Care Pathway Guidelines,” September 17, 2018, https://www.oireachtas.ie/en/committees/32/committee-on-health/documents/.
65 Starrs et al., “Accelerate Progress—Sexual and Reproductive Health and Rights for All.”, 2018 66 WHO.

Sexual health and its linkages to reproductive health: an operational approach.

(Geneva: World Health Organization, 2017).

Oireachtas Library & Research Service | Sexual and Reproductive Health and Rights 16 What is reproductive health?
“Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes.”67 Reproductive health implies that all people are able to: • receive accurate information about the reproductive system and the services needed to maintain reproductive health; • manage menstruation in a hygienic way, in privacy, and with dignity; • access multisectoral services to prevent and respond to intimate partner violence and other forms of gender-based violence; • access safe, effective, affordable, and acceptable methods of contraception of their choice; • access appropriate health-care services to ensure safe and healthy pregnancy and childbirth, and healthy infants; • access safe abortion services, including post-abortion care; • access services for prevention, management, and treatment of infertility.
What are sexual rights?
Sexual rights are human rights and include the right of all persons, free of discrimination, coercion, and violence, to: • achieve the highest attainable standard of sexual health, including access to sexual and reproductive health services; • seek, receive, and impart information related to sexuality; • receive comprehensive, evidence-based, sexuality education; • have their bodily integrity respected; • choose their sexual partner; • decide whether to be sexually active or not; • engage in consensual sexual relations; • choose whether, when, and whom to marry; • enter into marriage with free and full consent and with equality between spouses in and at the dissolution of marriage; • pursue a satisfying, safe, and pleasurable sexual life, free from stigma and discrimination; • make free, informed, and voluntary decisions on their sexuality, sexual orientation, and gender identity.
What are reproductive rights?

Reproductive rights rest on the recognition of the human rights of all couples and individuals to decide freely and responsibly the number, spacing, and timing of their children, to have the information and means to do so, and the right to attain the highest standard of reproductive health.
They also include: • the right to make decisions concerning reproduction free of discrimination, coercion, and violence; • the right to privacy, confidentiality, respect, and informed consent; • the right to mutually respectful and equitable gender relations.

(Source: Starrs et al., Accelerate Progress—Sexual and Reproductive Health and Rights for All.

Report of the Guttmacher-Lancet Commission, 2018) 67 UN.

Transforming our world: the 2030 agenda for sustainable development.

A/RES/70/1.
A/RES/70/1.

New York, NY: United Nations, 2015.
Oireachtas Library & Research Service | L&RS Note 17 Following a rigorous assessment of the evidence base for SRHR, the Lancet Commission reporting in June, 2018 recommended that every country provide an essential package of sexual and reproductive health interventions as outlined by the WHO – see Table 3: Table 3: Essential package of sexual and reproductive health services68 • Comprehensive sexuality education; • Counselling and services for a range of modern contraceptives, with a defined minimum number and types of methods; • Antenatal, childbirth, and postnatal care, including emergency obstetric and new born care; • Safe abortion services and treatment of complications of unsafe abortion; • Prevention and treatment of HIV and other sexually transmitted infections; • Prevention, detection, immediate services, and referrals for cases of sexual and gender-based violence; • Prevention, detection, and management of reproductive cancers, especially cervical cancer; • Information, counselling, and services for subfertility and infertility; • Information, counselling, and services for sexual health and wellbeing.
(Source: Starrs et al., Accelerate Progress—Sexual and Reproductive Health and Rights for All.

Report of the Guttmacher-Lancet Commission, 2018) 68 Starrs et al., “Accelerate Progress—Sexual and Reproductive Health and Rights for All.” Oireachtas Library & Research Service | Sexual and Reproductive Health and Rights 18 6.
Abortion as part of an integrated programme of sexual and reproductive health and rights (SRHR) in Ireland Ireland’s commitment to SRHR and evolving development of a comprehensive package of sexual health and reproductive services commenced with the International Conference on Population and Development (ICPD) in 1994 and continue through the Sustainable Development Goals.
The objectives of the National Sexual Health Strategy 2015-2020 continue to endorse international commitments to reduce negative sexual health outcomes, including crisis pregnancy, through the provision of high quality, equitable, accessible and targeted services.69 The services encompassed by the National Sexual Health Strategy represent a holistic vision of SRHR: clinical services for the diagnosis and management of STIs; contraception services/family planning services; counselling, information and support services; community outreach services for sexual health promotion; • • • • • education/information and support; and • crisis pregnancy management70 6.1 Crisis pregnancy counselling services in Ireland Crisis pregnancy counselling services called Positive Options are funded by the HSE Sexual Health and Crisis Pregnancy programme in 15 counselling services over 30 locations nationwide.
Counselling and the provision of information about abortion services outside Ireland are provided with parenting and adoption information as provided for by the Regulation of Information (Services outside the State for Termination of Pregnancies) Act 1995.

The decline in the demand for crisis pregnancy counselling (from 4,662 in 2010 to 2,570 in 2016) led to a review of the counselling service which proposed the establishment of a national crisis pregnancy telephone counselling service.
It is envisaged that this service will be available by the end of 2018.71 The WHO advocates that counselling services for abortion should ensure clarification of health- provider attitudes and beliefs with a commitment to confidentiality and privacy.
It is also suggested that the specific needs of women with disabilities, women who have experienced rape or intimate partner violence or may have been exposed to HIV or other STI’s must be included in the development and provision of abortion counselling.72 6.2 School-based relationships and sexuality education (RSE) Preventing crisis pregnancy and abortion is linked to qualitative programming for school-based sex education.
Women who have experienced sex education in schools are less likely to report having experienced rape, abortion or distress about sex.73 The United Nations Educational, Scientific and Cultural Organisation (UNESCO) and the WHO claim that sexuality education leads to improved sexual and reproductive health outcomes, including a reduction in sexually transmitted infections (STIs), Human Immunodeficiency Virus (HIV) and unintended pregnancy.74 However, sex education programmes alone will not offset 69 Department of Health, “National Sexual Health Strategy 2015-2020” (Dublin, 2015: p46).
70 Department of Health.

(2015:44) 71 HSE Sexual Health and Crisis Pregnancy Programme.

“Sexual Health in Ireland: What do we know?

(June, 2018) pp 26-27 72 World Health Organisation, “Safe Abortion: Technical and Policy Guidance for Health Systems.

Second Edition” (Geneva, 2012: 73).

73 Pound et al, 2016: 4 74 UNESCO, Emerging Evidence, Lessons and Practice in Comprehensive Sexuality Education: A Global Review (Paris: France, 2015); WHO.

Defining sexual health.


Report of a technical consultation on sexual health 28-31 January 2002.

Geneva: WHO; 2006 Oireachtas Library & Research Service | L&RS Note 19 other factors that have profound impacts on sexual, reproductive and other health outcomes.
Many factors combine to affect health and as such, sex education is unlikely to override - without other supports and services – the determinants of health in general.75 As indicated by Figure 2, while sexually active women in all fertile age categories are at risk of developing a crisis pregnancy, some groups are more at risk than others including younger women between the age of 18-25 years and early school leavers.76 The Lancet Commission on SRHR recommended school-based sexuality education as an evidence-based strategy that can realise improved knowledge and self-esteem “positively change attitudes, gender, and social norms, increase decision making and communication skills, delay sexual initiation, and increase contraceptive use”.77 Programmes addressing gender or power are five times as likely to be effective in reducing crises pregnancy and sexually transmitted infections,78 79 while multicomponent interventions that link school-based sexuality education with non-school-based youth-friendly health services report better sexual health outcomes overall.
80 Availability of Relationships & Sexuality Education (RSE) in Ireland Since 1997, RSE is a mandatory component of Social Personal and Health Education (SPHE) and must be provided to all students in both junior and senior cycles at post- primary level.
The junior-cycle covers: the stages of development from conception to birth;   different types of relationships;  awareness of the feelings and emotions associated with a variety of friendships;   skills necessary for making decisions consistent with personal values and within a the role of peer pressure and other influences in the area of sexuality; moral framework, about behaviours in relationships;  sexually transmitted diseases.
Depending on what the school decides, students may continue to develop their knowledge and understanding about the reproductive system, family planning, personal integrity, sexually transmitted diseases, sexual harassment, gender orientation, sexual discrimination, personal rights and personal safety and loving relationships.
Talking Relationships Understanding Sexuality Teaching Resource (TRUST) contains a number of lesson plans that support the delivery of the RSE programme including contraception and decision-making.
It is entirely at the discretion of the school and the SPHE department if it wishes to deliver on the topics.81 This programme is currently under review by the National Council for Curriculum Development (NCCD) (Source: Compiled by the L&RS from information provided by the Department of Education and Science as referenced) 75 World Health Organisation, Determinants of Health, http://www.who.int/hia/evidence/doh/en/ [accessed 17th July 2018) 76 Mayock, P. and Byrne, T., “A Study of Sexual Health Issues, Attitudes and Behaviours: The View of Early School Leavers CPAR Report No.8.
2004.” 77 Starrs et al., “Accelerate Progress—Sexual and Reproductive Health and Rights for All.” 78 Haberland, N., “Sexuality Education: Emerging Trends in Evidence and Practice.,” Journal of Adolescent Health 56 (suppl), no.

S15- 21 (2015).

79 Pound P, Denford S, Shucksmith J, et al., “What Is Best Practice in Sex and Relationship Education?

A Synthesis of Evidence, Including Stakeholders’ Views.

BMJ Open 2017;7:E014791.

Doi:,” n.d. 80 Pound P, Denford S, Shucksmith J, et al.
81 Adapted from an email received from the Department of Education and Science to the author on 6th July 2018 Oireachtas Library & Research Service | Sexual and Reproductive Health and Rights 20 For further information on the RSE programme in Ireland and the role of school-based sex education in preventing crisis pregnancy and abortion, see the L&RS Spotlight on school-based relationships and sexuality education (RSE): lessons for policy and practice.
6.3 Access to contraception in Ireland Abortion incidence declines as contraceptive use increases in countries with steady fertility rates.82 83 In one Irish study of sexual practices among young people, 80% of boys and girls, who had said that they were sexually initiated, reported using condoms the last time they had intercourse, while 20% of boys and 25% of girls reported using the contraceptive pill.
84 Condom use is therefore the most common method of contraception among young people, which is consistent with similar international studies.

Fourteen per cent used withdrawal (i.e.


practice of withdrawing the penis from the vagina before ejaculation), while 10% of boys and 6% of girls reported using no method of contraception at last intercourse increasing the risk of crisis pregnancy.85 Availability of Condoms in Ireland o Condoms are widely available to purchase throughout Ireland and they are subject to VAT at 13.5%.
However, condoms are made available through public STI clinics and are free-of-charge through a range of voluntary organisations working with people at risk of HIV or STIs or crisis pregnancy.
The National Condom Distribution Service (NCDS) was established in 2015 by the Sexual Health and Crisis Pregnancy Programme to distribute condoms and lubricant these organisations; o Approximately 15% of respondents to the Irish Study of Sexual Health and Relationships (ISSHR) in 2006 reported that reported that the cost of condoms discouraged their use, especially among young people.
86 (Source: Compiled by the L&RS from a synthesis of available data provided by the Sexual Health & Crisis Pregnancy programme, 2018 as referenced) Women who undergo an abortion appear to be more motivated than other women to use contraception.87 88 International evidence suggests therefore that post-abortion is an optimal entry point for contraception commencement89 90 and this is important in an Irish context given that non- use or inconsistent use of contraception is a factor in half of all reported crisis pregnancies in Ireland.91 The WHO recommends that women commence hormonal contraception at the time of surgical abortion or at the point at which abortifacients are administered.92 Pre-abortion counselling has been shown to have a limited impact on post-abortion contraceptive use.93 94 95 82 Marston C, Cleland J.
Relationships between contraception and abortion: a review of the evidence.

International Family Planning Perspectives 2003;29:6–13.

83 Wei-Hong Zhang, “Contraception Interventions for Women Seeking Abortion,” ed.

Yan Che et al., Cochrane Database of Systematic Reviews, no.

4 (April 9, 2014), http://search.ebscohost.com/login.aspx?direct=true&db=chh&AN=CD011067&site=ehost-live.

84 Ibid, 2018: 12 85 Ibid, 2018: 11 86 HSE Sexual Health and Crisis Pregnancy Programme.
“Sexual Health in Ireland: What do we know?

(June, 2018) pp 29 87 Speroff L, Mishell DR.

The postpartum visit: it is time for a change in order to optimally initiate contraception.

Contraception 2008;78:90–8 88 Zhang, “Contraception Interventions for Women Seeking Abortion.” 89 Speroff L, Mishell DR.

The postpartum visit: it is time for a change in order to optimally initiate contraception.
Contraception 2008;78:90–8 90 Zhang, “Contraception Interventions for Women Seeking Abortion.” 91 Ibid 92 World Health Organisation, “Safe Abortion: Technical and Policy Guidance for Health Systems.

Second Edition” (Geneva, 2012: 118).

93 Bender SS, Geirsson RT.

Effectiveness of preabortion counseling on postabortion contraceptive use.

Contraception 2004;69(6):481– 7.

94 Langston AM, Rosario L, Westhoff CL.

Structured contraceptive counseling - a randomized controlled trial.
Oireachtas Library & Research Service | L&RS Note 21 However, comprehensive interventions including personalised post-abortion contraceptive counselling with a range of contraceptive choices provided with follow-up has been shown to increase contraceptive use and decrease rates of repeat abortion.96 One systematic review found moderate evidence which suggested that inserting an intrauterine device (IUD) following an abortion is safe and that women are more likely to continue to use an IUD six months after an abortion if it is inserted immediately rather than some weeks after an abortion.97 A further study found very high continuation rates and protection from unintended pregnancy over 24 months in women using long-acting reversible contraception (LARC) like IUDs.98 A higher uptake of such contraceptive devices has been observed amongst women accessing sexual health services in the community rather than the hospital setting.99 Availability of Contraceptive Services in Ireland o The HSE Sexual Health and Crisis Pregnancy programme reports that LARC devices are provided on prescription in Ireland and free-of-charge to those with medical cards.
Partial cost-recovery is available through the Primary Care Reimbursement Service (PCRS) for non-medical card holders.

However, lack of training for both fitting and removing LARC devices was identified as a barrier to uptake but this is currently being addressed by an education and training programme provided by the Irish College of General Practitioners (ICGP).100 o Combined hormonal contraception is also available on prescription in Ireland and free to medical card holders.
This is the most commonly used form of contraception in Ireland although some misconceptions about side-effects have been reported, while 9% of young women report that cost is a barrier to refilling the prescription.101 o Emergency contraception is available without a prescription in Ireland through community pharmacies.

However, hormonal emergency contraceptive use is low and tends to be commonly used by young women.
While the majority of the population appear to be aware of emergency contraception, many women underestimate the effectiveness window.102 o Sterilisations are decreasing among women in Ireland and vasectomy (male sterilisation) is not evenly available across the country at primary care level.103 (Source: Compiled by the L&RS from a synthesis of available data provided by the Sexual Health & Crisis Pregnancy programme, 2018 as referenced) Patient Education and Counseling 2010;81:362–7.
95 Larsson 2006 Larsson M, Aneblom G, Eurenius K, Westerling R, Tyden T. Limited impact of an intervention regarding emergency contraceptive pills in Sweden - repeated surveys among abortion applicants.

The European Journal of Contraception and Reproductive Health Care December 2006;11(4):270–6.

96 Zhang, “Contraception Interventions for Women Seeking Abortion.” Pp2 97 Babasola O Okusanya, “Immediate Postabortal Insertion of Intrauterine Devices,” ed.
Olabisi Oduwole and Emmanuel E Effa, Cochrane Database of Systematic Reviews, no.

7 (July 21, 2014), http://search.ebscohost.com/login.aspx?direct=true&db=chh&AN=CD001777&site=ehost-live.

98 David Hubacher et al., “Not Seeking yet Trying Long-Acting Reversible Contraception: A 24-Month Randomized Trial on Continuation, Unintended Pregnancy and Satisfaction,” Contraception 97 (June 1, 2018): 524–32.
99 Cameron, Glasier and Johnstone, Comparison of uptake of long-acting reversible contraception after abortion from a hospital or a community sexual and reproductive healthcare setting: an observational study J Fam Plann Reprod Health Care.2017 Jan;43(1):31-36. doi: 10.1136/jfprhc-2015-101216.

Epub 2015 Dec 8.

100 HSE Sexual Health and Crisis Pregnancy Programme.

“Sexual Health in Ireland: What do we know?

(June, 2018) pp 50 101 Ibid 102 Ibid pp 51 103 Ibid.
Oireachtas Library & Research Service | Sexual and Reproductive Health and Rights 22 6.4 Other services 6.4.1 Sexual Assault Treatment Units (SATU) The six Sexual Assault Treatment Units (SATUs) in Dublin, Cork, Waterford, Mullingar and Letterkenny provide 24 hour clinical, forensic and supportive care for those who have experienced sexual violence.
SATU staff work collaboratively with allied agencies, including An Garda Síochána, Forensic Science Ireland, Rape Crisis Centres and Rape Crisis Network Ireland, paediatric forensic medical services and the Office of the Director of Public Prosecutions who together form the sexual assault response services.
In 2017, 865 men and women who disclosed rape or sexual assault attended a SATU clinic with a further 24 attending an out-of-hours service at University Hospital Limerick.104 Ninety-two per cent (n=798) of those attending SATU services were women, and 66 (8%) were men.

The mean age of patients was 26 years.


While 336 women presented within 120 hours of the alleged incident, and 334 (99%) of these received emergency contraception,105 a further 58% of women (n=462) attended SATU services later than the treatment window for administration of emergency contraception.
In her statement to the Committee on the Eighth Amendment of the Constitution, Dr. Maeve Eoghan, Medical Director of the SATU service in the Rotunda hospital reported that up to 99% of pregnancies are prevented when emergency contraception is provided within the 72 hour window.106 She added that pregnancy is infrequently encountered in those who attend SATU services and Rape Crisis Centre data shows that the rape-related pregnancy rate is 5%.107 However, women who become pregnant following sexual violence may only present after the first trimester of pregnancy thus limiting potential options.108 6.4.2 Reproductive healthcare services: detection of foetal abnormalities Ultrasound, invasive and non-invasive procedures may detect foetal abnormalities and these services are available throughout Ireland at any time during pregnancy.
However, Dr. Peter Boylan, Chair of the Institute of Obstetricians and Gynaecologists, reported that there are ‘infrastructural deficits’ in the provision of access to ultrasound in pregnancy in Ireland and warned the Joint Committee on Health on 19th September 2018 about the risk of introducing a termination of pregnancy service without adequate scanning facilities.
109 While routine pre-termination ultrasound scanning is not recommended as mandatory by the WHO, it is performed in circumstances where there are concerns about dating the pregnancy, ectopic pregnancy, or in the event that a woman requests an ultrasound scan.110 Currently, termination for foetal abnormality takes place outside the State and diagnoses is entirely based on ultrasound.
Dr. Boylan added in his statement to the Joint Committee on Health that in the United States and Europe, magnetic resonance imaging, MRI, is the standard of care and can change a diagnosis from fatal to life limiting.111 Furthermore, diagnostic accuracy of MRI is 93% compared to 68% for ultrasound.112 104 National Sexual Assault and Treatment Unit, Annual Key Service Activity Report.

Collated by Dr. Maeve Eoghan, Medical Director.


2017, pp3 105 Ibid, pp8 106 Joint Committee on the 8th Amendment of the Constitution, debate Wednesday 25th October 2017, Termination Arising From Rape: Mr. Tom O'Malley, NUI Galway; Dublin Rape Crisis Centre; and Dr. Maeve Eogan, Rotunda Hospital.

107 Ibid.

Rape Crisis Centre, 2015.


108 Ibid 109 Dr. Peter Boylan to the Joint Committee on Health, Clinical Guidelines for the Introduction of Abortion Services: Discussion, Wednesday, 19th September 2018 110 Dr. Peter Boylan to the Joint Committee on Health, Clinical Guidelines for the Introduction of Abortion Services: Discussion, Wednesday, 19th September 2018 111 Ibid 112 Ibid Oireachtas Library & Research Service | L&RS Note 23 7.
Key factors in the successful implementation of abortion services A recent comparative multi-country113 114 investigation of health sector strategies that involved Irish researchers explored some of the lessons learnt from the establishment of new abortion services.
Successful implementation was enabled by situating abortion as one component of a comprehensive reproductive health package (see sections 5 and 6 above), while including country- based health and women’s rights organisations, medical and other professional bodies, with international agencies and not-for-profit family planning organisations in the development and implementation of services.115 However, political will was found to be the primary success factor in establishing or expanding access to safe abortion services in this multi-country study.116 An earlier multi-country study117 118that examined the development and implementation of abortion services following the passage of abortion legislation found the need for publicity around the change in the legal status of abortion; formulation and dissemination of detailed medical guidelines for the provision of legal procedures; development of data collection and monitoring systems, with mechanisms for adequate financing as critical factors in successful implementation.119 This study also advocated the development of appropriate responses to resistance to new abortions laws.
A study that was intended to inform the WHO guideline on task sharing abortion services found limited documentation of the implementation processes undertaken but concluded that successful implementation of abortion services requires planners to consider health-worker motivation, support and working conditions.120 121 113 This multicountry study included Colombia, Ethiopia, Ghana, Portugal, South Africa, and Uruguay and as such the implementation lessons for these jurisdictions may not be transferable to an Irish context.
114 Chavkin W, Stifani BM, Bridgman-Packer D, Greenberg JMS, Favier M. Implementing and expanding safe abortion care: An international comparative case study of six countries.

Int J Gynecol Obstet 2018.

In Press.

115 Chavkin W, Stifani BM, Bridgman-Packer D, Greenberg JMS, Favier M. Implementing and expanding safe abortion care: An international comparative case study of six countries.

Int J Gynecol Obstet 2018.

In Press.


116 Political will emerged as the key factor in establishing or expanding access to safe abortion services.

117 This multicountry study included Cambodia, Colombia, Ethiopia, Mexico City, Nepal and South Africa and as such the implementation lessons for these jurisdictions may not be transferable to an Irish context.

118 Ashford L, Sedgh G, Singh S. Making abortion services accessible in the wake of legal reforms: A Framework and Six Case Studies.
Issues Brief (Alan Guttmacher Inst) 2012:1–4.

119 Ashford L, Sedgh G, Singh S. Making abortion services accessible in the wake of legal reforms: A Framework and Six Case Studies.

Issues Brief (Alan Guttmacher Inst) 2012:1–4.

120 Genton C, Ganatra B, Lewin S. Implementation considerations when expanding health worker roles to include abortion care: a five- country case study synthesis.

BMC Public Health 2017;17:730.


121 This multicountry study included Bangladesh, Ethiopia, Nepal, South Africa and Uruguay and as such the implementation lessons for these jurisdictions may not be transferable to an Irish context.

Oireachtas Library & Research Service | Sexual and Reproductive Health and Rights 24 8.
Conclusion The Office of the High Commissioner for Human Rights links women’s sexual and reproductive health to human rights, including the right to life, the right to be free from torture, the right to health, the right to privacy, the right to education, and the prohibition of discrimination.122 The Human Rights Committee and the UN Committee on Economic, Social and Cultural Rights have each criticised Ireland’s abortion laws, 123 while the UN Convention on the Rights of the Child and the Committee on the Elimination of Discrimination against Women have each expressed concern for the safety of young women and girls forced to travel outside the State in order to obtain and abortion.
124 125 Ireland’s commitment to SRHR commenced with the International Conference on Population and Development (ICPD) in 1994 and continues through national and international policy alignment with the Sustainable Development Goals.

The global policy framework for SRHR is reflected in the National Sexual Health Strategy 2015-2020126 and extended by the referendum on 25th May 2018 in which the electorate voted by a 66.4% majority to repeal the Eighth Amendment.
The characteristics of crisis pregnancy in Ireland reflect wider international trends: socio-economic status and higher educational attainment improve women’s ability to access information and services and to exert control over their sexual and reproductive lives.127 128 Sexual Health and Crisis Pregnancy programme studies have found that some women are more at risk of crisis pregnancy than others including younger women between the age of 18-25 years and early school leavers.129 Ireland is not unique in this regard as worldwide higher education is associated with improved access to health care, fewer births and better sexual health outcomes overall.130 Prevention of crisis pregnancy and abortion is linked to qualitative programming for school-based sex education and international evidence points to the fact that women who have experienced sex education in schools are less likely to report rape, abortion or distress about sex.131 However, sex education programmes alone will not offset other factors like socio-economic status or levels of educational attainment that impact on sexual, reproductive and other health outcomes.
Many factors combine to affect health and as such, sex education will not override - without other supports and services – the determinants of health in general including educational attainment and socio-economic status.
132 Most unplanned pregnancies result from inconsistent or incorrect contraceptive use133 while barriers to access include cost, which primarily affects younger age groups and negative attitudes towards women who carry condoms.134 Education programmes that address gender or power are five times as likely to be effective in reducing crises pregnancy and sexually transmitted 122 Office of the High Commissioner for Human Rights, Sexual and reproductive health and rights https://www.ohchr.org/en/issues/women/wrgs/pages/healthrights.aspx [accessed 2.10.2018] 123 Committee on the Rights of the Child, “Convention on the Rights of the Child: Concluding Observations on the Combined Third and Fourth Periodic Reports of Ireland” (United Nations, March 1, 2016).
124 Committee on the Elimination of Discrimination and against Women, “Committee on the Elimination of Discrimination against Women: Concluding Observations on the Combined Sixth and Seventh Periodic Reports of Ireland” (United Nations, March 9, 2017).

125 Committee on the Elimination of Discrimination and against Women.

126 Department of Health, “National Sexual Health Strategy 2015-2020” (Dublin, 2015: p46).
127 Jejeebhoy S. Women’s education, autonomy and reproductive behavior: experience from developing countries.

New York, NY: Oxford University Press, 1995.

128 United Nations Development Programme, “Human Development Report 2016: Human Development for Everyone” (New York, 2016).

129 Mayock, P. and Byrne, T., “A Study of Sexual Health Issues, Attitudes and Behaviours: The View of Early School Leavers CPAR Report No.8.

2004.” 130 Güneş PM.


The role of maternal education in child health: Evidence from a compulsory schooling law.

Econ Educ Rev 2015; 47: 1– 16 131 Pound et al, 2016: 4 132 World Health Organisation, Determinants of Health, http://www.who.int/hia/evidence/doh/en/ [accessed 17th July 2018) 133 Ibid.

pp36 134 McBride, O., Morgan, K. and McGee, H., Irish Contraception and Crisis Pregnancy Study 2010: A Survey of the General Population, Crisis Pregnancy Programme Report 24.
2012, HSE Crisis Pregnancy Programme: Dublin Oireachtas Library & Research Service | L&RS Note 25 infections,135 136 while multicomponent interventions that link school-based sexuality education with non-school-based youth-friendly health services report better sexual health outcomes overall.
137 Studies show that women who undergo an abortion are more motivated than other women to use contraception and as such post-abortion is an optimal entry point for contraception commencement.138 139 The WHO recommends that women commence hormonal contraception at the time of surgical abortion or at the point at which abortifacients are administered.140 Comprehensive care pathways that include personalised post-abortion contraceptive counselling with a range of contraceptive choices provided with follow-up has been shown to increase contraceptive use and decrease rates of repeat abortion.141 The implementation literature illustrates that political will is a key driver of successful implementation or expansion of abortion services.142 One international study pointed to the need for planners to consider health-worker motivation, support and working conditions when implementing new abortion services.143 144 However, Dr. Peter Boylan’s reported ‘‘infrastructural deficits” in the provision of access to ultrasound in pregnancy in Ireland and warned the Joint Committee on Health on 19th September 2018 about the risk of introducing a termination of pregnancy service without adequate scanning facilities.
145 The Guttmacher-Lancet Commission review concluded that abortion rates have declined globally and this trend is replicated locally with a 54% decrease in the number of women travelling from the Republic of Ireland to the UK for an abortion between 2001 and 2017.
Furthermore, the number of women accessing abortion in the UK who are not ordinarily resident there is the lowest in any year since 1969.146 However, the number of women accessing abortion pills in Ireland from one online provider tripled from 548 consultations in 2010 to 1,748 in 2016.147 It may be concluded that uptake of at‐home medical termination of pregnancy may account for the exponential decline in the number of women accessing termination of pregnancy procedures in the UK but other factors – including the possibility of more effective family planning – may also be at play.
Finally, the Department of Foreign Affairs and Trade in collaboration with the Department of Health have agreed negotiating guidelines for sexual and reproductive health and rights at international levels that reflect ICPD commitments and the provisions of the Protection of Life during Pregnancy Act, 2013.
The guidelines attempt to define the parameters of policy dialogue at international levels requiring a level of diplomatic balancing between Ireland’s commitment to SRHR and commitments to women in Southeast Asia and sub-Saharan Africa who continue to carry the global burden of maternal death from complications during pregnancy and unsafe abortion.148 135 Haberland, N., “Sexuality Education: Emerging Trends in Evidence and Practice.,” Journal of Adolescent Health 56 (suppl), no.

S15- 21 (2015).
S15- 21 (2015).

136 Pound P, Denford S, Shucksmith J, et al., “What Is Best Practice in Sex and Relationship Education?

A Synthesis of Evidence, Including Stakeholders’ Views.

BMJ Open 2017;7:E014791.

Doi:,” n.d. 137 Pound P, Denford S, Shucksmith J, et al.

138 Speroff L, Mishell DR.

The postpartum visit: it is time for a change in order to optimally initiate contraception.
Contraception 2008;78:90–8 139 Zhang, “Contraception Interventions for Women Seeking Abortion.” 140 World Health Organisation, “Safe Abortion: Technical and Policy Guidance for Health Systems.

Second Edition” (Geneva, 2012: 118).

141 Zhang, “Contraception Interventions for Women Seeking Abortion.” Pp2 142 Chavkin W, Stifani BM, Bridgman-Packer D, Greenberg JMS, Favier M. Implementing and expanding safe abortion care: An international comparative case study of six countries.

Int J Gynecol Obstet 2018.


In Press.

143 Genton C, Ganatra B, Lewin S. Implementation considerations when expanding health worker roles to include abortion care: a five- country case study synthesis.

BMC Public Health 2017;17:730.

144 This multicountry study included Bangladesh, Ethiopia, Nepal, South Africa and Uruguay and as such the implementation lessons for these jurisdictions may not be transferable to an Irish context.
145 Dr. Peter Boylan to the Joint Committee on Health, Clinical Guidelines for the Introduction of Abortion Services: Discussion, Wednesday, 19th September 2018 146 Department of Health and Social Care, “Abortion Statistics, England and Wales: 2017: Summary Information from the Abortion Notification Forms Returned to the Chief Medical Officers of England and Wales.,” June 2018.pp19 147 Ibid 148 United Nations Millennium Development Goal Monitor: MDG 5, Improve Maternal Health http://www.mdgmonitor.org/mdg-5-improve- maternal-health/ [accessed 2.10.2018] Oireachtas Library & Research Service | Sexual and Reproductive Health and Rights 26 Oireachtas Library & Research Service | L&RS Note 27 Contact: Houses of the Oireachtas Leinster House Kildare Street Dublin 2 D02 XR20 www.oireachtas.ie Tel: +353 (0)1 6183000 or 076 1001700 Twitter: @OireachtasNews Library & Research Service http://library Tel: +353 (0)1 6184701 Email: library.and.research@oireachtas.ie