As the dust settles from Ireland's historic decision to decriminalize abortion, doctors and activists debate how to implement a healthcare system that makes the procedure accessible for everyone.
A young woman stands in silent thought at the memorial of Savita Halappanavar during the Irish abortion referendum. Photo: Butler Photographic/Alamy Live News
The people of Ireland recently voted to repeal the Eighth Amendment, which has prohibited abortion in all but the most extreme circumstances since 1983. Now that Ireland’s pro-choice campaigners have won the political battle, they face a new set of challenges. Can Ireland fill the legislative and medical gaps left by a decades-long ban on abortion? What needs to be done to ensure the women of Ireland get comprehensive reproductive healthcare that works for them, and makes up for the failings of the past?
The main priority now for the Irish government is ensuring that new legislation must now be passed to provide for abortion in all circumstances up to 12 weeks. One concern with the proposed legislation is that it excludes trans people capable of pregnancy. Since 2015, the Gender Recognition Act has allowed Irish trans people to declare their gender freely, but the abortion bill currently specifies the word “woman.” Activists from the Transgender Equality Network Ireland (TENI) have expressed fears that the use of this word may prevent both trans men and non-binary people from accessing abortion.
“The day after the referendum, we immediately wrote to the Minister for Health Simon Harris,” TENI chief executive Stephen O’Hare tells Broadly over the phone. “It’s important for us to meet the minister and have a discussion around the best way to move forward with the legislation.”
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O’Hare is reluctant to guess what exact changes should be made to the legislation to make it more inclusive. He is positive about the future: “It feels like we’re pushing an open door,” he says. “We think the minister is very open to what we have to say. The bill has yet to go through its legislative process, and all groups who campaigned for abortion rights will be watching that process closely. So will we, and it is there that amendments can be made. Wording will be refined through a process of political debate.”
So how will existing gender recognition legislation and other laws feed into this process? “Well, under the Interpretation Act 2005, any legislation that appears to be gendered should be able to be read as gender neutral. The concern is that this would not cover the incoming abortion law. There may need to be more qualifying language introduced because of the definition of ‘woman’ in the legislation."
The current Gender Recognition Act doesn’t allow for non-binary self-declaration, O'Hare explains. (In January 2018, Ireland's Minister for Social Protection initiated a review of that Act to make it more inclusive.) "While one certainly feeds into the other," he concludes, 'it would be better to ensure that the abortion legislation is inclusive in and of itself, regardless of the outcome of the Gender Recognition review.”
O’Hare seems optimistic that the legislative vacuum left by the abortion ban can be filled in a way that is inclusive to the trans community. The new bill is likely to pass all stages of government by September, when it will be sent to the president for final approval.
But a legislative gap isn't the only thing Ireland has to worry about in the next few months. What about the gap in actual access?
Abortions on demand up to 12 weeks are expected to be available in Ireland from early 2019. Until now, Irish doctors have performed abortions in only the most extreme, life-threatening circumstances. Will doctors have to contend with a gap in medical knowledge and facilities that has been left by this decades-long denial?
Surprisingly, the answer may be no. Dr. Louise Kenny is a professor of obstetrics and a consultant obstetrician and gynaecologist. She was also a vocal advocate for Repeal. “From a gynecological perspective, there is no gap in medical knowledge in Ireland,” she says over the phone. “Most Irish experts who work in obstetrics trained in the UK, where abortion has been a recognized clinical option for decades.
“I have no doubt about the skills and knowledge of Irish medical professionals,” she continues. “I know GPs who are already mobilizing to get ahead of the curve. They’re in touch with the health minister, and mapping their resources. There is a huge willingness there—if the government is willing to resource it.
“If we’re serious about this, it needs to be rolled out comprehensively. The consultation, the procedure and the post-termination care should all be free, including counselling and reproductive planning.”
Recent reports indicate that the Irish government plans to set the price of abortion at around 300 euros ($350), with low-income individuals eligible to have costs waived. However, some abortion rights campaigners have expressed fears that not all low-income individuals will qualify for free care, as you need to be in possession of a state-issued medical card to waive costs. "There are many people who are not entitled to a medical card but would not be able to afford 300 euro," tweeted the Abortion Rights Campaign. "Should we force them to continue a pregnancy instead? Free abortion care means everyone can access the care they need when they need it.”
The government seem to be paying attention to these concerns. They have since announced they may seek to expand the Maternity and Infant Scheme (a program which allows for free maternity services when provided by a family doctor) to cover abortion—but nothing has been guaranteed as yet.
“We have a unique opportunity to get this right,” Kenny says. “Women don’t get an abortion after one ten minute consultation—they are going to need a couple of consultations, time and space to reflect, and to feel un-rushed.”
The Irish Family Planning Association have already stated they will provide a holistic package of abortion care as soon as the new laws are enacted, but the CEO Niall Behan emphasized that this depends on government resources. “The holistic package is critical,” Kenny continues. “We don't want to do this patchily. We have a real opportunity to do something transformative if we do it right.”
Rather than playing catch up, Ireland is now in a unique position to lead the world in abortion provision. “The 12 week window would mean that abortion in Ireland would be provided almost exclusively as a GP service, through primary care," Kenny explains. "This would reduce stigma around abortions by removing the need for specialist clinics. The patient would see their primary healthcare provider, and abortion would be treated like any other healthcare issue."
By administering the service primarily through abortion pills provided by GPs—rather than specialist clinics—women will be able to swerve the anti-choice protests often seen outside UK clinics. Harassment outside these clinics is so common, the UK government is considering legislating against it. The Irish Centre for Bio-Ethical Reform, an extremist anti-abortion group, is already picketing maternity hospitals in Ireland, prompting many to call for buffer zones around hospitals and clinics to protect women. But according to Kenny, Ireland may not need such legislation.
“By making abortion part of primary care, we can de-stigmatize it,” she explains. “It would be very difficult for anti-abortion groups to picket every GP in Ireland.”
If Irish campaigners can make the incoming legislation more inclusive and secure adequate resources for reproductive care, Ireland may not only avoid lagging behind—it may even become a world leader in reproductive health.
“We could go from zero to hero,” Kenny says.