Professor John Bonnar said:

Some of the abortions sadly relate to poor advice or lack of education in family planning. We want to help these women so that we will do our utmost to reduce the number who are seeking abortion as a solution to their social problems.

Dr Sean Daly said:

By improving sex education, improving contraception - making it more widely available - we should be able to reduce the number of unwanted pregnancies and clearly all, or a lot, of the efforts should be put into that. This is a much easier problem to prevent than ultimately to manage. I think if that was grappled with more aggressively then we could reduce the number of women who would look to terminate a pregnancy.

Professor Walter Prendiville said:

Essentially, I am saying that I believe - and I certainly think it is worth exploring - that education of very young people, accessibility of contraception and a responsibility to sexuality that prevails in northern Europe - and it does not prevail even in England nor in Ireland amongst our teenagers - is the only way we are going to change our society. I think that what we legislate for will actually not make any difference to 99% of the women who have an abortion.

This view was also strongly supported by Dr TK Whitaker:

If the legislative restrictions that I indicated stand up, I would be very happy not to have money or time spent on a referendum and more and more resources devoted to ... first of all, trying to ensure that there aren't unwanted pregnancies and then, if there are, that they are carried to completion with every help that the State can give and that the children of these pregnancies are helped to have good parents, whether their own mother or foster parents or adoptive parents.

The committee found widespread support for a plan to reduce the rate of abortion.

Thus, the Pro-Life Campaign:

While calling on the government to restore the fullest possible protection to the unborn, the Pro-Life Campaign also calls upon the government to tackle, in a creative and sensitive manner, the disturbing and growing number of crisis pregnancies. ... What is singularly lacking is a coherent government strategy for addressing what everyone agrees is the very disturbing rise in the number of Irish women seeking abortions in Britain. However, the rising trend of abortion is not inevitable. Statistics from Poland and certain areas in the USA show, when the conditions that pressurise women to opt for abortion are addressed, the trend can be slowed down and even reversed.

The Irish Congress of Trade Unions:

Increased resources should be made available to health boards, schools and family planning service providers, so as to enable more education, information and comprehensive family planning services to be available to all who require and need them.

The Well Woman Centre:

In the United Kingdom, one in every five pregnancies ends in abortion. In Ireland, one pregnancy in every ten ends in abortion - this in a country where abortion does not exist. Clearly, our education system is failing to equip young women and young men with information and a sense of personal responsibility regarding family planning. As far as Well Woman is concerned, the current high (and growing) numbers of Irish pregnancies ending in termination represents an embarrassing failure to educate our young people.

The Women's Education Research and Resource Centre:

... there is an urgent need for a significant restructuring of the health and educational systems so as to ensure that the promotion and protection of the health and well-being of women and girls is safeguarded and the scale of unwanted pregnancies in this country is reduced.

The Irish Family Planning Association:

The IFPA regrets to note that once again the government has allowed the blinding light of the abortion 'debate' to distract it from taking concrete measures to minimise unplanned pregnancy in the state. The committee would do great service by spurring the government to action in this respect, even before beginning an examination of the legislative and constitutional options.

Cherish:

Cherish acknowledges the importance of the function of education in the process of tackling crisis pregnancies. Cherish believes that all young people should be given the opportunity to gain for themselves the knowledge, skills and experience necessary to meet their own individual needs and those of others.

The Association of Irish Humanists:

Humanists do not regard abortion lightly as another form of fertility control. In fact we are firm advocates of education for life from an early age, with ready availability of all forms of family planning, emergency contraception etc., in order to reduce the number of induced abortions.

The Women's Health Council made one of the most developed submissions on the issue. It declared that:

Whichever of the seven legal options proposed by the Green Paper is implemented, crisis pregnancy will remain a reality in twenty-first century Ireland unless a specific, targeted, coherent and cohesive approach is taken to tackling its root causes and current outcomes.

It recommended that:

... a National Strategy be developed with the aim of reducing the rate of crisis pregnancy significantly over a short time frame. Such a strategy should involve policies, actions and initiatives at national, regional and local level, with a view to implementing evidence-based formal policy, procedures and programmes within five to ten years.

The elements of a plan

A plan to reduce the rate of abortion must:

a) seek to prevent as many crisis pregnancies as possible from occurring

b) ensure that where crisis pregnancies do occur, women have the knowledge and understanding to allow them to make a decision based upon all of the options open to them - abortion, lone motherhood or adoption.

a) Preventative measures

Education Education is the first instrument that people who wish to tackle a social problem usually reach for. People tend to equate knowledge with virtue - if you know what is good you do what is good. This has led to demands for more and more courses to be placed on the heavily laden curricula of the schools. The courses often require that teachers be given special formation in order to be able to deliver them. Sometimes there is compelling criticism that a new subject may overload the curriculum. Curriculum designers may respond to this by seeking to have the elements of the programme delivered through a number of existing courses at second level. To deliver a civics programme, for instance, one might target history, geography, religion, economics and home education. This stratagem, however, requires extraordinary feats of co-ordination by the teachers.

The committee is aware of the limited value that can be placed on education programmes. It is also aware of how difficult it is to create the attitudes and skills that personal and social education programmes aim to achieve - such as assertiveness and self-discipline. In spite of this the committee believes that the community must make an exceptional educational response to the exceptional problem it faces in trying to reduce the rate of abortion.

It is also aware of the need, in relation to the problem of abortion, to help the development of good relationships within the family so as to create a primary supportive context for the girl who finds herself with a crisis pregnancy. An education programme must provide support for parents. They are currently a neglected resource.

The educational sector has already responded. In 1995 the Stationery Office published Relationships and Sexuality Education - the report of the expert advisory group chaired by senior inspector Emer Egan. The group first of all set its work in the context of our educational culture, stating:

The Irish education system has as a general aim the development of all aspects of the individual. Any programme which seeks to educate the whole person must have due regard for relationships and sexuality education as part of that total programme. While in law parents are the primary educators of their children, research has shown that many look to schools for support in helping them fulfil their obligations in this very important aspect of their children's development.

It defined relationships and sexuality education as a lifelong process of acquiring knowledge and understanding and of developing attitudes, beliefs and values about sexual identity, relationships and intimacy. This education is delivered consciously and unconsciously by parents, teachers, peers, adults and the media. It pointed to certain aspects of contemporary life that called for relationships and sexuality education:

· earlier physical maturation of children · evidence of earlier sexual activity · the informal and unsupervised contexts within which children acquire information about sexuality · the changing roles of men and women in society · health issues related to sexual practice · young people becoming aware through travel, the media and the communications revolution, of different sexual mores and cross-cultural influences · pressures on family life.

In 1997 the Department of Education and Science began a process of introducing Relationships and Sexuality Education (RSE) in both primary and second-level schools. The intention is that this will be incorporated into the Social and Personal Health Education (SPHE) which will become part of the core curriculum.

Teachers have been trained, schools are developing policies on RSE and materials have been produced in order to provide effective relationships and sexuality education for all Irish young people.

Health boards have also had an important role in establishing services to reduce unhealthy sexual behaviour among young people at risk, outside of the school setting. One example is the Teenage Health Initiative of the Eastern Regional Health Authority. This programme is specifically targeted at young people in disadvantaged areas who have been identified as being at risk.

The Green Paper points out that the following issues need to be considered and debated:

- education on the use of contraception is not currently included in the RSE curriculum. Further consideration needs to be given to how best to ensure that young people have access to full information in this regard

- the need for approaches other than a school-based one, e.g. community-based 'outreach' programmes, media-based educational campaigns. Teenage health initiatives on the lines of those developed by the Eastern Regional Health Authority could be extended to other boards

- educational campaigns designed to cultivate more responsible attitudes to alcohol, with particular regard to alcohol and sexual activity and the risks involved

- educational programmes targeted at parents to encourage the open discussion of sexuality in the home.

Notwithstanding these educational initiatives, the Women in Crisis Pregnancy study makes it clear that there is considerable ignorance of fertility cycles and a lack of knowledge about how to ensure effective contraception. The organisers of the '5000 Too Many ... Reducing the Abortion Rate by Providing Real Alternatives' conference, Breda O'Brien and Professor Patricia Casey, point out that countries such as the Netherlands are realising that giving young people skills to avoid early sexual activity is crucial and that information is not enough. They say boys are often completely neglected in RSE and that modules should be developed emphasising the role of fathers and the responsibility attached to every act of sexual intercourse. They say that in view of Women in Crisis Pregnancy, which showed that fear of parental disappointment was a key factor in choosing abortion, parental involvement should be part of any RSE programme on an ongoing basis, not just part of a consultative process in formulating school policy. They point out that information on alternatives to abortion was neglected during the eighties because students' unions were focused on access to abortion information. A working group on alternatives to abortion should be set up on each campus. It should aim to provide clear unambiguous information on the supports available to those continuing pregnancies. It should concentrate on areas where students convene or instinctively seek information, such as student handbooks and websites.

In its written submission the Women's Health Council also recommends the implementation of comprehensive relationship and sex education programmes at all levels of the educational system:

The programmes should cover inter alia sexuality, fertility and methods of contraception, information on safe sex practices and a module raising awareness about violence against women. Male responsibility should be a major factor in any education programme concerning sex, contraception and reproduction.

Breda O'Brien points out that encouragement of young people to use contraception does not address all of the issues involved:

... Douglas Kirby is recognised as the prime researcher in sex education in the United States. ... He made an interesting comment in 1991 and I can leave this with you rather than reading out the sources and references. He said it may actually be easier to delay the onset of intercourse than to increase contraceptive practice. That has been borne out around the world. I have a number of references which I will not go into but according to The Guardian on October 13 last year, the British Pregnancy Advisory Service in a study of 2,000 women who had sought abortions said contraception cannot be relied on to prevent pregnancy in the UK; the New Zealand Medical Journal, 1994, a study of women - the British Pregnancy Advisory Service of women presenting for abortion, fifty-nine percent of them cited contraceptive failure. That was thirty-eight percent condom failure and seventeen percent pill failure. If contraception were the answer there would be no abortions in Britain and if contraception were the answer there would be no abortions in the US either. A similar study in New Zealand - again women presenting for abortion - sixty-one percent of women had been using a method of contraception in the month they got pregnant. Some twenty-five percent had been using the pill, twenty-nine percent using condoms that experienced failure. The most interesting statistic for me is that one-fifth, approximately twenty percent, had been using contraception perfectly. It was not human error. It was pure contraceptive failure. Then there is an Irish study by Dr Maeve Robinson which was 163 patients attending an Irish family planning clinic. Of 163 patients, 83 had used contraception and experienced contraception failure. So there is no magic bullet. It would seem intuitively that the way to go is to encourage young people to use contraception but it does not seem to be that way.

What is emerging from the United States ... the American Government has recently mandated $250 million for what they call 'abstinence education'. I prefer the term 'delaying sexual activity'. The RSE - Relationships and Sexuality Education the proper term for it - is just a module within social, personal and health education. I think that is a much more healthy way of looking at it. As advocates of health, can we be advocating to young people that contraception is the answer to everything, particularly condoms, particularly when we have a growth in the incidence of human papilloma virus which condoms do not protect against and which are implicated in cervical cancer?

The implications for young women engaging in sexual intercourse at an early age are much more serious than for young men. Young men do not escape unscathed but young women have much more serious consequences. Chlamydia, which has reached epidemic proportions in the United States, actually results quite often in pelvic inflammatory disease which results quite often in infertility. These are very serious things that we need to look at when we are advising young people. I think we have this ... I was talking to a group of young people recently and this person, a very bright, articulate young woman, said to me the media are not remotely interested in the seventy percent. I said: 'what seventy percent'? She said the seventy percent that are not sexually active, the ones who do not go off the rails, the ones who are quite sane and sensible, we are quite boring, you never hear about us. We have concentrated all our efforts on the thirty percent and have assumed that the seventy percent are an aberration and that we cannot move the statistics in the other direction, that the seventy percent must become lower and the thirty percent must become higher. The evidence from the United States is very promising in that it can be done. The average age of losing virginity has increased by a year, which is significant if you think of young people over the past number of years since the mandating of the DSA - delaying sexual activity - model ...

The committee is aware from its knowledge of other social programmes which require responses from government departments, public bodies and voluntary organisations that a single focus is indispensable. Without a single focus it is highly unlikely that research would be carried out in a programmed way, that the endeavours of the implementing bodies would be sufficiently co-ordinated and that the necessary public response would be galvanised. The planning structure proposed in the next chapter would provide this.

Contraception An education programme aimed at placing sexuality in a wholesome relationships context and proposing delayed sexual activity as an ideal but also providing information on contraception is a positive, but necessarily limited, factor in a plan to reduce crisis pregnancies. Contraceptive services, including post-coital emergency contraception (the morning after pill), are probably a more important factor.

A range of family planning and health services is currently provided by the health boards, general practitioners and other agencies such as the Irish Family Planning Association and the Well Woman Centres.

The Green Paper identifies the following issues as needing to be settled:

- the availability of the widest possible choice of service for women seeking advice on and services for contraception

- the production of an information booklet or leaflets which would be widely available regarding the correct and safe use of contraceptives

- improved access to contraception, including identification of and extension of services to meet current unmet needs

- the availability of contraception at little or no cost to everyone who needs it

- improved access to emergency contraception, especially outside the major urban areas

- more widespread availability of sterilisation and vasectomies as part of the public health service

- an examination of the role of GPs in the provision of family planning services.

Women and Crisis Pregnancy confirmed findings of earlier research that many women who have abortions did not use contraception or used it incorrectly. The study found that social and personal factors militated against consistent use of contraception. The fact that young women were sexually active was not generally disclosed to their parents. Many believed that their parents would disapprove or be shocked if they found this out. This included a fear of contraceptive pills being discovered by parents, concern over how their doctor might respond to a request for the pill, and a fear that being on the pill would result in women being perceived as sexually available. Many women were therefore reluctant to use the pill unless in a long-term relationship.

The study also found that women felt that to carry condoms was to compromise their reputation. However, the principal impediment to the effective use of condoms was found to be the failure of men to assume responsibility for contraception. In the face of objections from their partner, some women were not assertive about condom use, fearing that insistence would threaten their relationship. As a result, effective contraception was compromised.

A plan needs to be drawn up which would provide contraceptive services in all parts of the country and to all the people who need them. As the Adelaide Hospital Society recommended in its written submission, the government should introduce a national network of contraceptive provision, including a number of choices for adolescents (family medical practitioners, Family Planning and Well Woman clinics, hospitals, community nurse specialists etc). The emphasis should be not just on availability but also on accessibility, especially for the poor, the young and the socially deprived sections of our community. Provision of contraception and education should be made as far as possible according to people's choice.

Post- coital contraception The evidence the committee heard on emergency contraception suggested that it was strategically important to a plan to reduce crisis pregnancies. Dr Harith Lamki, a consultant obstetrician and gynaecologist in the Royal Maternity Hospital in Belfast, told the committee:

... in the Royal Maternity Hospital we run a very big morning after pill clinic, which means we have a big reduction in the number of unwanted pregnancies at present.

Evidence of whether the morning after pill, which prevents a fertilised ovum from being implanted in the uterine wall for a period of about seventy-two hours following fertilisation, is an abortifacient was heard by the committee. The problem centres on when the unborn comes into being. Some would argue it is when an ovum is fertilised. However, great numbers of fertilised ova are lost in the natural course of things and never become implanted in the uterine wall. As a result some argue that implantation is the decisive event in the development of unborn life.

Professor Gerard Bury, President of the Medical Council, was asked if a doctor who prescribed the morning after pill would be acting unethically. He said:

It currently is a part of normal practice that hasn't been challenged or, in fact, even addressed within the ethical guidelines. It is seen as normal practice.

Dr James Clinch, asked about use of the morning after pill, said:

If you actually believe that there is a child there I don't think you will use the pill ... if you don't believe there is a child there you will use it. And if you have doubts you will, in fact, go along with your doubts. So, I think that people who sincerely believe that there is a child there will not use it.

The Family Planning Act 1979 specifically prohibits the importation, sale and distribution of abortifacients. In as much as the morning after pill is available and prescribed the legal presumption must be that it is not regarded as an abortifacient. Reverend Father Paul Tighe, lecturer in moral theology and a representative of the Irish Catholic Bishops' Conference, when asked about the Roman Catholic Church's position in regard to the administration of the morning after pill after rape, said:

In 1986, the British and Irish bishops' bioactive committee looked precisely at this issue and it examined the main form of morning after pill that was commonly administered in those circumstances [rape]. It said that the morning after pill could be effective in two ways: it could be effective by preventing conception occurring or it could also be effective by acting as an abortifacient by preventing implantation. It said that if, in the circumstances of rape, where an act of violence has been done and there is no obligation on a person to conceive, if the morning after pill could be taken with a safe expectation that it were likely to be effective as a contraceptive, then it was morally licit to do so - even if you could see that there was that risk, that side effect, that it could actually act as an abortifacient if the person were already pregnant. But if it were prudent in the circumstances to judge that it was being administered as a contraceptive measure, then that would be morally licit.

This test might reasonably be applied to all cases where emergency contraception is needed. In any event, the committee attaches importance to the general availability of the morning after pill. The availability of the morning after pill can help to reduce the number of crisis pregnancies. Any legal uncertainties that may exist in regard to it should be removed.

The committee received some evidence on the failure rate in condom use and on the effectiveness of condoms against some sexually transmitted diseases. Contraceptive services must, therefore, be based on scientific assessment and young people especially must be well informed on any risks involved in their use.

Given the complexities involved in this programme, the need for a single planning focus is evident.

b) Options in crisis pregnancies

The second part of the plan must seek to deal with the crisis pregnancies that will occur in spite of education and contraceptive services. In regard to crisis pregnancies, the state must ensure that options other than abortion are promoted. Before dealing with these options, however, it is necessary to deal with two elements which affect in a general way the perception of all the options - social understanding and counselling/information.

Social understanding A pregnancy develops into a crisis because of the personal, relationship and social issues that shape a woman's life at the time of her pregnancy. Women and Crisis Pregnancy describes the factors influencing the decisions of those women who decide to have an abortion. It found that women frame their decision making in the context of competing conflicts and demands on their lives.

The reasons women seek abortion were the subject of two major US studies by Dr Charles Kenny. The first important finding that emerged was that women seek abortion because they believe that their life will end if they have the baby. By that they do not mean physical life, but life in a broader metaphysical sense encompassing career and family prospects.

Popular attitudes and lack of understanding puts pressure on women with crisis pregnancies to opt for abortion. There is a need for a vigorous programme aimed at promoting a proper social understanding for women in crisis pregnancies. A second major finding of the US studies was that women who seek abortion acknowledge the reality that they are carrying a baby and that the foetus is a human being. Consequently, programmes of prevention directed at trying to convince women that the baby is human are misplaced and unnecessary - women already know that.

Another valuable component of a social understanding programme was presented to the committee by Professor Patricia Casey - the projection of positive images of motherhood. Professor Casey outlined an advertising campaign that was carried on national television stations in many states in the US. These advertisements were conducted from the perspective of the expectant mother. The advertisements painted a picture of the turmoil of the woman and then gave images of possibilities that exist for that woman. The advertisements projected the conviction that women can overcome the crisis and can go on to live positive, fulfilling lives if they choose the option of continuing the pregnancy. It appears from pre- and post-assessment studies that there has been a reduction in the numbers seeking abortion in jurisdictions where these advertisements were shown.

A social understanding programme needs a single planning focus to sustain it.

Counselling/Information The Regulation of Information (Services outside the State for Termination of Pregnancies) Act 1995 established an entitlement to receive counselling and information on abortion services available abroad. The Act stipulates that counselling must be non-directive and, where abortion is discussed, must also include a discussion of all other options. A range of agencies provide pregnancy counselling and some receive financial assistance from the Department of Health and Children towards the provision of such a service. Not all of these agencies will provide women with information on how to obtain an abortion.

In the area of counselling/information, general practitioners, with their special knowledge and geographical distribution, form an important element of the counselling/information network. The Irish College of General Practitioners (ICGP) produced an information booklet for general practitioners in 1995. The booklet says that, reflecting the reality in society at large, there exists amongst general practitioners a diversity of opinion regarding the issue of abortion outside the state and the dissemination of information toward that aim. The 1995 Act recognised an entitlement to seek abortion information and counselling and the right of doctors to refuse to co-operate in this process.

The booklet continues:

However, GPs are united in their desire to help any woman with a crisis pregnancy. Quite apart from moral considerations abortion is medically undesirable and, with appropriate use of contraception, should be preventable. Yet the numbers seeking abortion in Britain does not appear to have fallen. Many women bypass their GPs when travelling for an abortion and receive no medical follow up afterwards. That is a situation which the vast majority of GPs would like to change.

In response to the Women and Crisis Pregnancy report the ICGP postgraduate resource centre recommended that the ICGP should:

· support the provision of a comprehensive family planning service within general practice

· support the provision of pregnancy counselling within general practice

· provide initial and ongoing education and training to facilitate the provision of these services

· provide appropriate assistance for provision of these services, in terms of patient education leaflets, posters, guidelines for doctors etc.

· support the establishment of inter-referral protocols to facilitate a comprehensive service within general practice

· examine ways in which GPs could convey to the public the range of services they are willing to provide

· examine ways in which the public can be informed of the confidentiality of the doctor-patient relationship.

The rights of doctors who have a conscientious objection to abortion or contraception are recognised and supported. They may exercise the legal right to inform women of their disagreement with or objection to abortion or contraception. This objection does not absolve the doctor from a duty of care for a patient distressed by a personal crisis.

However, counselling services do not seem to match the requirements. The Green Paper observes:

A number of submissions cite inadequate provision of current counselling services as contributing to the numbers having abortions. They say that many women receive no counselling before making a decision to have an abortion. There also appears to be a lack of clarity about the position of General Practitioners and agencies who do not provide counselling on all of the options. ... Submissions seek the provision of a national network of non-directional crisis pregnancy counselling services which would be free of charge and available on request. Appropriate training of all staff involved in counselling is also considered a priority.

Women and Crisis Pregnancy found that thirty-three percent of women who had an abortion obtained information about the clinic which they attended from a source other than a doctor or agency in Ireland - in other words they did not use the counselling route at all. Another group attended their general practitioner, but not all doctors were willing to provide counselling, and some did not provide information on abortion as an option. The study found that charges and waiting periods for appointments with some counselling agencies acted as a disincentive. Women's expectations and requirements of the counselling agencies varied, ranging from seeking information only to seeking a full discussion on their pregnancy and all of the options which they should consider.

The study concluded that a significant number of women lacked information on the availability of counselling services and that many women decide on abortion without receiving any counselling. Many are unclear about the availability of counselling and the legal position on information and there was some dissatisfaction at having to undergo counselling as a prerequisite to information.

In their submission to the committee the organisers of the '5000 Too Many ...' conference, Breda O'Brien and Professor Patricia Casey, raised other issues on counselling:

Currently women who choose abortion do so almost immediately and resent what they perceive as the imposition of counselling. This implies a distrust of the counselling process. Research should be conducted as to the training and accreditation of counsellors. Deficiencies have already been shown, for example, in their understanding of present adoption practices

Currently, the only model available is non-directive counselling. Some believe strongly that there is no such thing as non-directive counselling, only non-manipulative counselling. Would a more honest approach be to attempt to provide women and men with the clearest available information on surgical procedures, potential risk to physical and mental health, stage of gestation and so on?

In this context, Right to Know laws such as passed in American states should be investigated. A mother must be given state produced materials at least twenty-four hours before an abortion. These include pictures of foetal development, information about the nature of the medical procedure, its risks both physical and psychological, information about alternatives and lists of local social service organisations which provide assistance to pregnant women. At the moment, a woman receives medical information, if at all, just before she is required to sign consent for the operation.

Right to Know laws passed in Pennsylvania resulted in an eighteen percent drop in first time abortions.

Even in the case where a woman chooses abortion, receiving respectful care and counselling can decrease the risks of subsequent medical and psychological difficulties.

The Women's Health Council proposed the structural change of detaching information from counselling. They recommend:

· information on all crisis pregnancy options including abortion should be available. This will involve severing the link between compulsory counselling and accessing information on abortion

· accessible, free, unbiased pregnancy counselling services should be available throughout the country for all women

· a standard approach to the provision and content of both information and counselling services should be set up with accreditation, agreed codes of practice and evaluation built in. Although regulation has been introduced by the Department of Health (1995) on the dissemination of information on abortion no such directive has been issued for information on crisis pregnancy or counselling. For the reassurance of the prospective users the Department of Health and Children should ensure that crisis pregnancy information and counselling meets agreed standards

· crisis pregnancy counselling services should also be available to women who are considering continuing the pregnancy.

Women and Crisis Pregnancy pointed out that the most likely outcome of a crisis pregnancy is lone motherhood. Women facing lone parenthood have to devise and negotiate new strategies and they need practical and emotional support to adapt to this role. Current pregnancy counselling services are perceived by the majority of the women in the study as directed at women who are considering abortion or adoption.

The Council also gave its support to the Irish College of General Practitioners recommendation on the establishment of inter-referral protocols between general practitioners to facilitate a comprehensive service within general practice. The service includes pregnancy counselling. A system is necessary to distinguish those general practitioners who provide this service from those who have a conscientious objection to abortion or contraception.

As is clear from the above discussion, the counselling/ information element is also complex and will benefit from a single planning focus.

Lone motherhood In Irish society traditional culture expects pregnancy and motherhood to take place within the context of marriage. Non-marital births have been, and continue to be, of social concern. The proportion of non-marital births has been increasing. In 1980 five per cent of the total births were non-marital, whereas by 1997 over twenty-six per cent were. As the Green Paper says:

However, while pregnancy and motherhood outside marriage have become more common and more acceptable, such acceptance is by no means widespread or unqualified. For many women there continues to be a social stigma associated with pregnancy outside marriage or a long-term stable relationship. There continues to be public debate about the growing proportion of births to unmarried mothers and whether it is in children's best interests to be brought up in a single-parent family. For a significant number of women with unplanned pregnancies, having a baby outside a marital or a long-term stable relationship is problematic, because of family, social, educational or career considerations.

Currently the majority of single mothers continue with their pregnancies and become lone parents, a very small percentage have their babies adopted, while thirty per cent of non-marital conceptions are aborted (Women and Crisis Pregnancy). The difficulties faced by women with crisis pregnancies who decide to take the option of single parenthood are presented in Women and Crisis Pregnancy:

Expectant single mothers are especially vulnerable socially, financially and emotionally. They are heavily dependent on the support systems of partners and parents. Unlike women seeking abortion or adoption, many in this group did not find support agencies with services to match their needs as they prepared to become single mothers. The support of family and partner was crucial, however. Some women also found that they had to cope with the stigma attaching to non-marital pregnancy. Work or education arrangements had to be revised to take account of the pregnancy. The degree to which parental or partners' assistance with childcare arrangements was forthcoming had a bearing on the continuation of education plans. Those who remained in their jobs while pregnant were in better-paid, skilled positions, with maternity benefits and these women anticipated being able to afford private childcare.

Maureen Gilbert, an independent member of the Women's Health Council, told the committee that practical supports are necessary:

I think the stereotypical image of a lone mother in a bleak block of flats struggling to bring up her child is seen to be not only very bleak for that mother but particularly bleak for the child and, therefore, is perhaps not the option that people want to choose, and equally the well documented links between lone motherhood and poverty and some notion that again you would not be just reducing yourself to a life of poverty but also reducing your child to a life of poverty.

The Women's Health Council, therefore, proposed that the negative image of single mothers should be addressed with practical programmes targeted to address economic and social factors. Economic and social policy development should reflect the reality that there is no longer always an adult working full time in the home. Statutory childcare provision, adequate social housing and access to training and educational programmes (providing childcare) are necessary to begin to change the way people view the social and economic conditions of the single parent.

Women and Crisis Pregnancy suggests that ongoing support and counselling should be available to alleviate demands and anxieties created by the pregnancy and anticipated motherhood and that educational and training institutions should support young pregnant women by encouraging them and facilitating them in every possible way to continue with their education. The committee heard of some of the difficulties in achieving the right balance in a programme of support for lone motherhood from Breda O'Brien, one of the organisers of the '5000 Too Many ...' conference:

We do not want to increase, inadvertently by trying to reduce the numbers of those seeking abortion, the numbers of lone parents because, unfortunately, the reality is that it is an indicator of poverty, it is an indicator for long-term dysfunction. So there's a very delicate balancing act here but I think it is one that could be tackled. We have the resources, we have the research and the people capable of doing it.

It was clear to the committee that the lone parenthood element also requires a multi-faceted programme and would benefit from a single planning focus.

Adoption Legal adoption was introduced to Ireland by the Adoption Act 1952. Adoption was a popular option where birth took place outside marriage in the decades which ensued. The practice peaked in 1967, when ninety-seven per cent of non-marital births were adopted. Since then there has been a decline. For example, in 1984 there were 898 children placed for adoption by health boards and registered adoption societies. By 1997 the number had fallen to 108.

The Green Paper suggests that a combination of factors has led to the majority of unmarried mothers now keeping their babies:

These include more enlightened attitudes to births outside marriage, greater family acceptance and support, greater State supports, improved opportunities for combining career with single motherhood, some negative media coverage of adoption. The availability of abortion outside Ireland means that women who do not want to continue with a pregnancy may decide to have an abortion and this of course has also affected the number of babies being placed for adoption.

One of the negative factors for a woman considering placing her baby for adoption is that she must carry the baby for nine months, give birth and then face the trauma of being parted from her baby. Because there is no statutory provision for 'open adoption' in this country, the birth mother must resign herself to the possibility that she may never see her child again.

Maureen Gilbert told the committee that what will give a child the best start in the world is a big factor in what path is chosen in a crisis pregnancy.

At the moment, the view of adoption is quite ambivalent in this area, that on the one hand a mother may feel that by having her child adopted this will give the child the best start in the world, in another way she may feel she will be very much criticised for giving away her child and so on. So, I think it is a particularly tricky option and perhaps particularly at this time, where there has been so much discussion of it.

Professor William Binchy, representing the Pro-Life Campaign, referred to the development of new forms of adoption:

Two things that were understandably very heartrending for the mother would be the secrecy aspect and the finality aspect of adoption, that it is goodbye to your child forever more and it is a total termination of relationship. The whole trend, legally speaking, internationally now is towards open adoption. Elements of this have crept into the Irish system slowly, breaking away the notions of secrecy for example, and the whole notion of the finality aspect can also in terms of goodbye to a child, never seeing the child again, that is the area where the heartrending pain came in. If those areas can be broken down and have a form of informal adoption which has been worked quite successfully - and incidentally has been part of the culture of many countries for generations but is increasingly coming into the English speaking countries - that would take away some of the anxieties that the choice involves in those circumstances.

Breda O'Brien pointed out that newer forms of adoption were very demanding in terms of resources:

Open adoption or semi-open adoption demands much more resources because the adoption agencies are, basically, undertaking to keep two parties - the adoptive parents and the original birth parents - in contact for a minimum of eighteen years. That is obviously very demanding on everybody involved. Neither Professor Casey nor I would like to advocate that adoption would be a majority solution but that it could be a solution for more women than it is currently.

Women and Crisis Pregnancy indicated that women who intended to have their baby adopted viewed the issue in terms of their own circumstances rather than those of potential adoptive parents. These women tended, on moral grounds, to have rejected abortion from the outset. They had also rejected lone motherhood at this stage of their lives, because of the unfavourable view they had of such a situation, which they considered would have entailed dependence either on their family or on social welfare. They also felt that they would have to forgo future educational and employment opportunities and that they were not in a position to cater for their child's emotional and financial needs at this stage of their lives. These women wanted to maintain secrecy about their pregnancy because they felt that if their pregnancy was disclosed they and their families would be stigmatised. Secrecy would allow them to make a decision about adoption without being influenced by others. They were accommodated by agencies which care for women who adopt. After the pregnancy they were able to return to their community without any substantial change in their identity.

The study found that there was a lack of information available to women about adoption and the availability of services which facilitate adoption, including residential homes. It also indicated that once women moved into a residential home setting they were usually unable to continue with work or training. The study found that there was a need for better counselling for the women and their families. It also found that the women had no specific knowledge about their rights or those of the putative father in relation to their children.

The committee concluded that adoption required a positive promotion and this promotion would benefit from a single planning focus.

c) Post-abortion services

There is much secrecy in relation to the experiences of the women who travel from Ireland to have an abortion abroad. From the evidence available it is clear that many of them never receive post-abortion counselling or a medical check up.

Medical check-up The Institute of Obstetricians and Gynaecologists in their written submission, stated:

We recognise our responsibility to provide aftercare for women who decide to leave the State for termination of pregnancy. We recommend that full support and follow up services be made available for all women whose pregnancies have been terminated, whatever the circumstances.

The Irish College of General Practitioners in their training and information package, recommend that general practitioners should arrange a follow-up service for women who have consulted them two to four weeks after they have had an abortion:

Post-abortion medical check-ups are also important, because of the possible risks to women's health, particularly their reproductive health, should any complications go undiagnosed. Such a check-up also provides the opportunity for women to obtain advice on appropriate contraception for the future and thereby reduce the incidence of further unwanted pregnancies.

The Women's Health Council recommends that post-abortion check-ups must be easily available to women to protect their health and well-being. It should be clear to women who need them where they can go for post-abortion check-ups in a non-judgmental setting.

A medical check-up programme needs to be vigorously developed and promoted.

Post-abortion counselling The pregnancy counselling agencies which receive funding from the Department of Health and Children provide post-abortion counselling as part of their service and it is desirable that women who have had an abortion avail of this.

The organisers of the '5000 Too Many ...' conference recommend that post-abortion counselling should be provided free, with due recognition of the psychological complications of the procedure.

A post-abortion counselling programme needs to be vigorously developed and promoted.

Drawing the plan together

Thus far the committee has been analysing the elements of a plan aimed at reducing the rate of abortions carried out on Irish women abroad. The committee examined the features of crisis pregnancy and the source of decisions to have abortions. The committee identified education and contraceptive services as essential preventive measures.

The committee then examined options in crisis pregnancies, where preventive measures failed. The Regulation of Information (Services outside the State for Termination of Pregnancies) Act 1995 obliges counsellors of women in crisis pregnancies to present in an objective and non-directive manner the options available to them. The committee analysed how options other than abortion can be made as attractive as possible. The committee analysed two elements that affect the choice of a woman in a crisis pregnancy: the general social understanding of her plight and her awareness of the counselling/information services that are available. Hence there are four crucial elements in a policy on crisis pregnancy - social understanding, counselling/information, motherhood and adoption. Each requires a programme.

Finally, the committee examined the care that might be provided for those women who have chosen to have an abortion. The committee identified two elements in post-abortion services: post-abortion counselling and medical check-ups. Hence the third element of the plan - post-abortion services, would consist of two programmes, namely post-abortion counselling and medical check-ups.