Hello, it’s Órla Ryan here. Welcome to today’s liveblog of the Oireachtas Eighth Amendment Committee.
The agenda for the meeting is as follows: Ancillary recommendations of the Citizens’ Assembly Report. The witnesses are officials from the HSE and the Department of Health.
You can watch proceedings below:
iPhone/iPad users: click here. Streams provided by HEAnet.
While we wait for today’s hearing to begin, here’s a round-up of what happened at yesterday’s meeting – where committee members said they will vote on 13 December on whether or not the Eighth Amendment should be repealed.
Here are the Citizens’ Assembly’s ancillary recommendations on the Eighth Amendment, which were published back in June:
The committee is meeting in private session, we’ll let you know when the public hearing begins.
Dr Tony Holohan, Chief Medical Officer of the Department of Health, is now delivering his opening address:
“The first ancillary recommendation which I will address concerns improved access to reproductive healthcare services including contraception, sexual health services and termination of pregnancy.
“With regard to contraception and family planning services, the Department of Health launched the National Sexual Health Strategy 2015-2020 in October 2015.
“The Strategy is being implemented under Healthy Ireland, the National Framework for Improved Health and Wellbeing. It is a cross-governmental policy which is being delivered in partnership by the Department of Health, the HSE and the Department of Education and Skills.
“The National Sexual Health Strategy’s key aims are to improve sexual health and wellbeing, and to reduce negative sexual health outcomes. The Strategy aims to ensure that everyone in Ireland will receive comprehensive and age-appropriate sexual health education and information, and will have access to appropriate prevention and promotion services. It also aims to make equitable, accessible and high quality sexual health services, targeted and tailored to according to need, available to everyone.
“I will not address the service provision aspects of the National Sexual Health Strategy here, as I believe our colleagues from the HSE will be addressing the area in their presentation to the Committee today.
“However, just to note that implementation of the Strategy got underway quickly, with an Action Plan for 2015-2018 prioritising 18 actions covering areas such as clinical services, education, communications and governance/structures. All of those actions have commenced, and 10 have already been completed.
“These include the appointment of a Clinical Lead for Sexual Health within the HSE, and the reconfiguration of the HSE Crisis Pregnancy Programme to also encompass sexual health as the new HSE Sexual Health and Crisis Pregnancy Programme.
“In terms of achieving good quality outcomes, the Department of Health considers that full implementation of the National Sexual Health Strategy, together with the measures outlined in the National Maternity Strategy (which I will shortly address), will significantly advance the good quality outcomes envisaged by the Citizens’ Assembly.”
Dr Holohan continues: “The second ancillary recommendation which I will address concerns standards of obstetrical care in Ireland.
“Over recent years there has been a very significant focus on the development of national maternity policy in order to ensure that our maternity services are developed in a coherent and evidenced based way. Last year, we published Ireland’s first ever National Maternity Strategy Creating a Better Future Together 2016 – 2026.
“The HSE’s National Standards for Bereavement Care following Pregnancy Loss and Perinatal Death were also published in 2016, and I will speak a little more about those later.
“Finally in 2016, Hiqa’s National Standards for Safer Better Maternity Services were launched on 21 December 2016. They aim to give a shared voice to the expectations of women using maternity services, service providers and the public. They are intended to show what safe, high-quality maternity services should look like.
Each of the 19 maternity units is now required to publish a Maternity Patient Safety Statement on a monthly basis. The first Maternity Patient Safety Statements were published in December 2015. The Statements are published monthly in arrears, and report information on 17 metrics covering a range of clinical activities, major obstetric events, modes of delivery and clinical incidents.
“Taken together, these developments are key building blocks which will enable us to provide a consistently safe, patient-centred, high quality maternity service. They will also help advance the quality outcomes envisaged by the Citizens’ Assembly in its ancillary recommendations.”
“In terms of overall governance structures, a National Women and Infants Health Programme has been established within the HSE, to lead the implementation of the National Maternity Strategy. It will span obstetrics, gynaecology and neonatal services across community, primary, and secondary care.
“The Programme will oversee the establishment of maternity networks across the country, which will formally link all maternity units within a Hospital Group.
“It is recognised that smaller maternity services cannot, and should not, operate in isolation as stand-alone entities. Given their size, those units cannot sustain the breadth and depth of clinical services required by the populations they serve. Through the establishment of maternity networks, we will ensure efficiency in the provision of specialised services, and support smaller units to provide safe, quality services.
“I am aware that a key concern of the Citizens’ Assembly in its ancillary recommendation was that all pregnant women, regardless of geographic location or ability to pay, should have access to early scanning and testing.
“On this point, the National Maternity Strategy is very clear that all women must have equal access to standardised ultrasound services. We know that there are challenges, but we intend to build capacity in our ultrasound services. To that end, additional funding will be provided to the National Women and Infants Health Programme in 2018 to develop a more equitable and consistent antenatal screening service.
“The recently published Maternity Strategy Implementation Plan addresses the current regional inconsistency in service provision.
“Pending full implementation of the Strategy’s recommendations on anomaly scanning, the National Women and Infants Health Programme will continue to work with the six Hospital Groups to assist in increasing access to anomaly scans.
“In particular, the Programme will seek to ensure that clinical pathways are in place within each network, such that where clinically indicated, a woman can be referred to a larger maternity unit for an anomaly scan,” he states.
Speaking about the ancillary recommendation on improving counselling and support facilities for pregnant women, Dr Holohan says: “I do not propose to go into too much detail on the service delivery side, given that my colleagues from the HSE are also addressing the Committee today and are likely to cover the area in more detail. I am also aware that you have previously had speakers before you on this area from the HSE Sexual Health and Crisis Pregnancy Programme.
“So I will just note briefly that the HSE Sexual Health and Crisis Pregnancy Programme funds the provision of crisis pregnancy and post abortion counselling services, which operate out of more than 40 locations nationwide. All services also provide access to post-termination counselling and a number provide free post-termination medical check-ups.
“The National Maternity Strategy pointed to the need to improve access to mental health supports and to that end a number of recommendations are made. The Maternity Strategy Implementation Plan addresses the issue and sets out specific actions to identify women at risk and ensure that they get the necessary support during their pregnancy and postnatally.
“I might draw the attention of the Committee again to the National Standards for Bereavement Care following Pregnancy Loss and Perinatal Death which, as I mentioned earlier, were published last year. We anticipate that the Standards will drive the development of clinical and counselling services within our maternity services.
“The Standards describe the standardised structures, clinical processes and compassionate responses that should be in place across all maternity services for parents who experience a pregnancy loss or perinatal death. They will also apply in situations where there is a diagnosis of foetal anomaly that may be life limiting or fatal.
“The linkages between maternity bereavement care and other hospital and associated services such as primary care, public health nursing and palliative care are also outlined. Each hospital will have to have systems in place to ensure that bereavement care and end-of-life care for babies is central to the mission of the hospital and is organised around the needs of babies and their families.
“Implementation of the Standards has begun, and bereavement teams are being established in each maternity unit/hospital.”
“In addition, I should mention that the HSE is today launching a Perinatal Mental Health Services Model of Care for Ireland. I won’t go into too much detail, as I expect it is an area that my colleagues in the HSE will expand on.
“However, I would like to note that the Model of Care is closely aligned with the National Maternity Strategy, and contributes to the implementation of the Strategy’s actions on mental health. The Model is based on the maternity networks recommended in the National Maternity Strategy; this means specialist perinatal mental health services will be aligned with hospital groups and developed to include all 19 maternity units. It is a significant development in addressing the mental health needs of women both during pregnancy and in the year following delivery,” he says.
Dr Holohan continues: “Finally, the Citizens’ Assembly recommended that further consideration should be given as to who will fund and carry out termination of pregnancy in Ireland.I will preface my remarks here by pointing out the obvious and saying that action in this area will be subject to your deliberations here and the Oireachtas decision on recommendations you decide to make.
“It will also, obviously, be subject to the outcome of the referendum which the Government has committed to holding next year. Terminations of pregnancy carried out in Ireland at the moment – under the Protection of Life During Pregnancy Act 2013 – are limited to public obstetric units or large public multidisciplinary hospitals.
“That is to say, they are only done in the public system and are funded by the State. It was appropriate that terminations took place in obstetric units to ensure all the expertise and facilities appropriate to provide safe medical services, and ancillary services, to pregnant women whose lives were at risk and to the unborn.
“Other than in emergency situations, doctors who can certify – permit access to – a procedure under the Act must be registered by the Medical Council in its Specialist Division.
“At the moment, a termination of pregnancy may only be carried out by or under the supervision of a Consultant Obstetrician. This is irrespective of whether the medical procedure for carrying out the termination is by medical or surgical means.
“On this point about medical terminations of pregnancy I must note that there are currently no medicines indicated for the termination of pregnancy authorised for such use in Ireland.”
“In the event of a significant change to the Constitution and to current policy around the use of drugs for medical termination, it would be the responsibility of the manufacturers of such medicines to seek a marketing authorisation for such use in Ireland.
“This would be in line with the normal procedure for authorising any medicines to the Irish market. The Health Products Regulatory Authority (HPRA) is the competent authority responsible for the regulation of human medicines in Ireland. It has a structured assessment procedure in place for conducting this assessment process.
“If there is a change to the Eighth Amendment and if the grounds for termination of pregnancy are widened, then this may have implications for the health services. Pending a decision on the policy direction, the Department of Health is working with the Office of the Attorney General and the Department of the Taoiseach to explore and research the Constitutional and policy issues involved. This is so that as much preparation as possible can be drawn upon if a referendum on the matter is called next year.
“Once direction is clear, consideration will be given to the issue of funding and carrying out terminations of pregnancy in Ireland, and to drafting legislation in order to achieve good quality outcomes.
“In conclusion, Madame Chair, I wish to thank you and your fellow Committee members for the opportunity to address you today. I would like to wish you well with your work, and look forward to your report,” Dr Holohan concludes.
Liam Woods, Director of the HSE’s Acute Hospitals Division, is now delivering his opening address:
“Perinatal mental health features strongly in the National Maternity Strategy, recognising the potential impact it has on the mother, baby and the wider family. The National Women & Infant’s Health Programme’s (NWIHP) implementation plan sets out a series of actions aimed at identifying at risk women, and ensuring that they get the appropriate support throughout their pregnancy and during the postnatal phase. These actions include:
“The appointment of clinical midwife specialists in each of the 19 maternity hospitals/units, to support and train midwives in identifying and supporting at risk women. Recruitment of additional perinatal psychiatrists, so that each maternity network has a minimum of one perinatal psychiatrist.
“In line with the perinatal mental health model developed by the HSE’s Mental Health Directorate, a hub and spoke model will exist within each maternity network, with the psychiatrist based in the tertiary facility accepting referrals from individuals units, and supported, as required by local liaison psychiatry.
“The training of all staff working in maternity hospitals/units to identify women at risk at booking appointments, or throughout their maternity journey, and in particular those with a mental health history.
“While these developments are resource dependent the implementation process will commence with the launch of the HSE’s implementation plan for the National Maternity Strategy. Perinatal mental health is a significant priority for the HSE’s National Women and Infants’ Health Programme.
“The actions in the implementation plan will focus on providing the necessary support and counselling to women who are showing signs of stress and anxiety at the lower end of the spectrum, as well as those who have a underlying history of mental illness in the higher risk categories.
“The pathway for women will depend on the risk classification from their assessment. The model of care for perinatal mental health is being launched today by the Mental Health Division of the HSE and we will arrange for information to be provided to the Committee on its content.”
He continues: “The Model of Care is based on the maternity networks recommended in the National Maternity Strategy. This means the specialist perinatal mental health services will be aligned to hospital groups and developed in a hub and spoke format so all 19 maternity services are included in the model.
“An allocation €1 million has been made in 2017 to start three specialist perinatal hubs in Galway University Hospital, Cork University Maternity Hospital and University Maternity Hospital Limerick and to expand the small existing teams in the Dublin based maternity hospitals (Coombe; National Maternity Hospital; Rotunda).
“A further €2 million has been allocated for 2018 to complete each of these 6 hub teams. The Model of Care recommends the establishment of a National Mother and Baby Unit. This will require further investment.”
“In August 2016 the HSE launched the National Standards for Bereavement Care following Pregnancy Loss and Perinatal Death. These standards set out care that families can expect following a maternity related bereavement. An implementation team has been established, and a clinical lead and programme manager have been appointed.
“The implementation team are visiting all 19 units to support the implementation of the standards. In 2016 resources were secured to appoint a Clinical Midwife Specialist in Bereavement to all maternity hospitals/units that did not already have one. Recruitment to fill these important posts is currently underway.
“The provision of services and supports to women and their families experiencing a crisis pregnancy is part of the remit of the Sexual Health and Crisis Pregnancy Programme (SHCPP). The SHCPP is one of a number of National Programmes led by the Health and Wellbeing Division of the HSE.
“My colleagues Janice Donlon and Helen Deely presented to you in relation to the work of the Programme on 15 November 2017, and Janice is here today to provide any further inputs you may require. The SHCPP presented on the current provision of counselling services in Ireland as funded by them and the range of supports available to women both during a crisis pregnancy and following termination,” Woods tells the committee.
“As you will be aware from their presentation the HSE SHCPP currently fund fifteen individual crisis pregnancy counselling services which operate out of 40 plus locations nationwide to provide free crisis pregnancy counselling, these services are in a mix of rural and urban locations. Details of these crisis pregnancy counselling services can be found on www.positiveoptions.ie.
“Crisis Pregnancy Counselling and the provision of information on all three options; Parenting, Adoption and Abortion is provided under the legal framework of Regulation of Information (Services outside the State for Termination of Pregnancies) Act 1995. The Act sets out how information about legal abortion services outside Ireland may be given to individuals or groups in Ireland,” he adds.
Speaking about scanning and testing, Woods says: “The National Maternity Strategy “Creating a Better Future Together” sets out the road map for ensuring that all women can access standardised high quality, safe care regardless of location.
“The HSE has developed and published an implementation plan for the National Maternity Strategy, which seeks to address the current regional variations in provision of anomaly scanning as part of the overall approach. The implementation plan will be overseen by the HSE’s National Women and Infants’ Health Programme (NWIHP).
“The HSE’s maternity services will be managed through maternity networks, with larger tertiary centres working collaboratively with smaller regional centres.
“The provision of a dating ultrasound in the late first trimester (12-14 weeks) followed by a detailed foetal (anomaly) scan at 20-22 weeks is a recognised component of good antenatal care. Currently only seven maternity hospitals/units offer 100% of women access to anomaly scans, and five units do not offer any access.
“As part of the implementation plan for the National Maternity Strategy, the NWIHP have identified the need for an additional 52 sonographers to support the provision of both dating and anomaly scanning in all 19 maternity hospitals/units.
“In 2018 the priority will be on improving access for anomaly scanning, and funding for approximately 40 additional sonographers, subject to the approval of the HSE’s National Service Plan for 2018, will be provided.
“Sonographers are a difficult grade to recruit, and if suitably qualified personnel are not available, then existing staff will be trained to develop the required capacity. While this will take time, the recruitment of the additional staff will improve access.”
Speaking about who will fund and carry out terminations in Ireland should the law change, he states: “In the first instance this will be a policy matter for the Department of Health in the event of any changes in the legislation being passed in the future, following which the HSE may be invited to submit additional service proposals for funding through the HSE’s annual Service Plan and Estimates processes.
“This concludes my opening statement and together with my colleague we will endeavour to answer any questions you may have.”
Replying to Solidarity-People Before Profit TD Bríd Smith, Dr Holohan says the Department of Health is looking into what changes may need to be made in Ireland in terms of abortion, without preempting whatever decision will be made in this regard.
He says the department is preparing for “an array of decisions” so the HSE can implement changes as quickly as possible.
When asked by Smith about women who’ve used abortion pills seeking aftercare from doctors, Dr Holohan says medical professionals are there to help people, not judge them.
Speaking about staffing levels, Woods tells Smith the HSE is currently hiring more nurses. He says if there’s a difficulty in hiring sonographers, current staff may have to be trained in this regard.
He notes that information on services is available in different languages in order to be more inclusive of women from migrant backgrounds.
Replying to Fianna Fáil TD James Browne, Woods says the recruitment of perinatal psychiatrists is a priority.
Killian McGrane, National Programme Director of the National Women & Infant’s Health Programme (NWIHP), adds that the goal is for each of the country’s 19 maternity hospitals/units to have at least one perinatal psychiatrist.
Responding to independent Senator Rónán Mullen, Janice Donlon of the HSE’s Sexual Health and Crisis Pregnancy Programme says non-directive, non-judgmental counselling is good practice.
“It is their decision in terms of what pathway they make,” Donlon says of the patient.
Mullen asks who gets to define what good counselling practice is, saying he doesn’t believe non-directive counselling is used when helping a suicidal person, for example.
Dr Holohan says “the role of the practitioner is to support people in making decisions”, rather than make decisions for them.
Fine Gael TD Kate O’Connell says, from her experience as a pharmacist, she’s aware there is “a huge amount of ignorance surrounding folic acid” and the role it plays in helping prevent neural tube defects during pregnancy.
Dr Holohan says he “agrees completely” with O’Connell’s points, noting there has been a “concerning” increase in neural tube defects in Ireland.
Dr Peter McKenna, Clinical Director NWIHP, says it’s “unrealistic” to expect women who don’t plan on becoming pregnant to take folic acid every day. He mentions that some foods such as wheat could be fortified with folic acid. Senator Chair Catherine Noone interjects to say some people are against this, likening it to anti-fluoridation arguments.
Speaking about the availability of extra scans, O’Connell says this would help put women’s minds at ease during pregnancy.
Replying to Sinn Féin TD Jonathan O’Brien, Dr Holohan says there is no other legislation here that affects the type of healthcare women receive.
Dr Holohan says there isn’t a record of the number of women who apply to have a termination under the Protection of Life During Pregnancy Act 2013 but are unsuccessful.
In 2015, one woman appealed a decision made in this regard, under section nine of the Act (mental health grounds). She was granted a termination. Two women did the same in 2016, both of whom were found to qualify for terminations under the Act.
Fine Gael TD Peter Fitzpatrick says it’s “very, very cruel” to use an injection to end a pregnancy up to eight months of gestation.
Dr Holohan says it’s not up to doctors to decide what’s legal.
“My thing is finding alternatives to abortions,” Fitzpatrick says, adding that both the mother and the unborn child should be supported.
“To me adoption would be an ideal alternative to having an abortion,” he says.
Dr Holohan says adoption falls under the Department of Children, rather than Health. Donlon adds that women who seek information about abortion are “absolutely” supported.
Fitzpatrick referred to contraception ending a baby’s life, but later clarified that he misspoke and wanted the record corrected.
Clare Daly, Independents4Change TD, brings up making contraception free, noting: “Prevention is better than cure.” Donlon says a study into the logistics of this would be welcomed.
Dr McKenna says there are “extensive waiting lists for gynaecological procedures”, noting this couldn’t happen in terms of abortion so any change in this area must be properly resourced.
“The earlier it’s done in pregnancy the safer it is,” Dr McKenna says of abortion.
Daly says having access to the abortion bill would be a cheaper, better option for many women. Dr Holohan says there are 2,500 GPs in the country and abortion pills could be administered in a primary care setting.
He adds that the Department of Health is looking into what changes may need to be made if abortion is legalised here, ahead of a referendum next May or June.
Replying to Sinn Féin TD Louise O’Reilly, Woods says the HSE will aim to recruit sonographers and other extra staff in 2018.
McGrane says seven of the country’s 19 maternity units can provide access to a 20-week anomaly scan, seven have limited access and five have no access (based on UCC research published earlier this year).
He says about 64% of pregnant women are currently offered the scan, adding that more work needs to be done to increase this figure.
Replying to Social Democrats TD Catherine Murphy, Donlon says, in relation to any potential changes in legislation, the HSE’s Sexual Health and Crisis Pregnancy Programme would be in a position to offer more counselling and other services.
Dr McKenna says the risk of a 14-year prison sentence may be a concern to medical practitioners in relation to abortion, but he’s not aware of anyone being jailed in this regard.
Speaking about contraception, Dr McKenna says educational and financial barriers should be removed. Dr Holohan adds that sexual health education plays an important part in this regard.
Responding to Fine Gael TD Bernard Durkan, Dr McKenna says there are adequate services in place to deal with a crisis pregnancy situation including one where the woman or girl presents with mental health issues.
He says current legislation enables doctors to discuss termination as an option if the mother’s health is at risk.
Dr Holohan notes that “multiple barriers” exist for patients in certain situations, but that more people than before are aware of the services they are entitled to.
In relation to counselling, the committee hears that, as of September, six of the country’s 19 maternity units have been unable to recruit a clinical midwife specialist in bereavement – with a high level of burnout given as one of the reasons why.
Noone notes this would be a “challenging” role. She then brings the conversation back to an earlier point about fortifying foods such as wheat with folic acid, something she’d be in favour of.
McKenna agrees that this topic should be looked at again.
Speaking about problems recruiting and retaining staff in the health service, McKenna says many people choose to not work in Ireland because they can earn more money and have a better work-life balance elsewhere.
When asked by Noone about the feasibility of universal access to contraception, Dr Holohan says this needs to be looked at in more detail and that he can’t make a commitment in this regard.
Kate O’Connell notes that earlier this month Helen Deely, head of the HSE Sexual Health and Crisis Pregnancy Programme, told the committee research shows about 18% of people not in receipt of the medical card find the cost of contraception prohibitive.
Discussing further changes that could be made in this area, Noone says the sexual health education curriculum has not been fully overhauled since 1999.
Noone thanks today’s speakers before ending the hearing. The committee will meet again on Wednesday afternoon.
We will be sending out an email round-up of what happened at the committee later today. To get the weekly round-up, just enter your email in the box at the bottom of this article.
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