• SUNDAY, FEBRUARY 17, 2019
  • ISSN 2399-1623
Ailsa Campbell

Abstract

It is unlikely that the debate on abortion in Northern Ireland will soon reach a conclusion, as there is still significant political and religious unrest in the country. For women and medical practitioners to feel safe under the current law, there must be some clarification on its interpretation in practice. Increased pressure to release the official guidelines is, therefore, a matter of priority. In addition, the recent ruling that Northern Irish women must pay for abortion services in England means that there is significant health inequity between those who have the money to travel and pay for private care and those that do not. This is further compounded by the difficulty some women face when trying to access services abroad when they suffer social stigma and pressure. For this inequity to be addressed in any real sense, it is imperative that Stormont and Westminster look again at this issue and either make treatment free through the mainland NHS, subsidize women’s costs of travel and treatment, or change the law such that women are able to access abortion and reproductive services more readily. Through addressing important related factors at a grass-roots level, it may be possible, in time, for Northern Ireland to bring itself back into line with the rest of the UK on this issue and ensure equity for women’s reproductive rights.


The debate over the decriminalisation or legalisation of abortion in Northern Ireland has been ongoing for many years – with an escalation in intensity in recent times. The opening of the first Marie Stopes centre in Belfast in late 2012 ( 1 ), almost coinciding with the death of Savita Halappanavar in the Republic ( 1 ) brought the debate to the fore. Opposition to liberalisation is rooted primarily in the majority Christian beliefs of the population. With 93.5% of the population identifying, or having been brought up, as Christian ( 2 ), and almost all denominations condemning abortion to some degree ( 3 ), it is possible to understand why it may be difficult for many of the population to reconcile their beliefs with supporting abortion. The core belief is that life begins at conception ( 4 ), and, therefore, the life of the foetus is of equal value to that of the mother ( 5 ). In Northern Ireland, the two leading political parties, the DUP and Sinn Fein, are affiliated with the Protestant and Catholic sectors of society respectively ( 6 ). Despite Catholicism being classically more condemnatory of abortion ( 3 ), Sinn Fein have recently opposed moves by the DUP to further restrict laws on abortion, and have endeavoured to make the law more liberal ( 7 ). These difficult and complex political, cultural and religious dimensions of Northern Irish society and Government make the issue an interesting and multi-faceted topic to investigate.

I would like to argue from the standpoint that the current legislation creates great challenges for health equity for women in Northern Ireland when compared to those in the rest of the UK. I will argue that the unavailability of current guidelines creates an unsafe environment for women and medical practitioners, thereby forcing women into the difficult situation of travelling to the mainland UK for treatment under the NHS. I will further this by looking at the social, moral and religious stigma attached to abortion in Northern Ireland and how this impacts on women’s reproductive freedom and choices available to them. I will also address how this stigma can be nurtured from a young age through the reproductive education provided in religious schools in the country.

The law regarding abortion in Northern Ireland is based upon the Offences against the Person Act, 1861. In the rest of Great Britain, medical practice is governed by the The Abortion Act, 1967. Health governance is a devolved issue, so this legislation does not apply within Northern Ireland. This means that, unlike England, Scotland and Wales, Northern Ireland imposes stringent regulation on abortion. Legal conditions for abortion are: if the mother’s life is in danger, or the pregnancy poses a risk of long-term damage to her physical or mental health. The law does not allow for cases of sexual crime, such as rape or incest, or cases where the foetus suffers from a severe handicap ( 8 ). Women may travel to other countries, such as the other British nations, to have an abortion but they are required to pay for these services – sometimes costing up to £2000 ( 9 ). They are able to request advice regarding this option within Northern Ireland, but the procedure cannot be performed unless within the legal framework i.e. not for therapeutic use. The Marie Stopes clinic provides the same service as the Northern Irish NHS, in that it has to follow the same guidelines ( 1 ).

A major barrier to women accessing abortion services in Northern Ireland is that there is currently no guideline document available which clarifies the extent of the law. Such a document was produced by the Department of Health, Social Services and Public Safety (DHSSPS) in 2009 after years of lobbying by the Family Planning Association, resulting in a number of court hearings and appeals. This was then removed after it was ruled that two sections of the document were not clear enough. An updated version was circulated in 2013 but is yet to be formally published ( 10 ). This makes it difficult for patients and medical staff to know what is possible within the law. This leads to the majority of abortions taking place elsewhere – normally in England. Statistics show that only 23 women underwent legal abortions in Northern Ireland in 2013/14 ( 11 ). The lack of guidelines raises questions about the equity of reproductive health services access within Northern Ireland as each regional board can interpret the law differently, or medical staff may refuse to treat on the grounds that they may face legal retribution should they misinterpret the law. This was one of the principal reasons given for the tragic death of Savita Happalanavar in the Republic – lack of understanding of the law led medical staff to conservative treatment options. Her family still blame this indecision, and lack of guidance, for her death ( 1 ). Medical staff are also entitled to conscientiously object to giving advice or performing abortions on religious or moral grounds, and this is more likely to happen in some councils than others. All these factors create a “postcode lottery” situation where women can expect different standards of care depending on which county they live in ( 8 ).

If there is no NHS doctor available or willing to perform the necessary consultations, preliminary tests or final treatment, the patient has to be referred to other councils which can delay treatment to the point where they are outside the timeframe for having a legal abortion. This limits them to the options of paying for private treatment, travelling abroad for treatment or not having it at all ( 8 ). In the rest of the UK it is possible to have an abortion procedure free under the NHS, but women from Northern Ireland are not legally entitled to this. This means that despite being UK taxpayers, they still have to pay for an abortion in the other British nations as services are provided on area residents-only basis ( 1 ). The cost of an abortion in the UK can be prohibitively expensive for women in Northern Ireland – further suggesting that this may contribute to health inequity in the country as only those with the money to pay can access reproductive healthcare. Those who cannot may resort to seeking out illegal options and risk lengthy prison sentences. This can expose them to risky techniques – such as “backstreet abortions” or abortion pills bought online ( 9 ). These carry poorer health outcomes than legal abortions such as “injury, infection, infertility and even death” ( 12 ). Exposing women to risks such as these can be seen as a form of sex-discrimination, and the FPA recently appealed to the United Nations Committee on the Elimination of Discrimination Against Women on the issue of abortion – appealing them to look closely at the current situation in Northern Ireland ( 13 ). The outcome of this was that the Committee reviewed the UK, and remarked that it “regrets that a public consultation on the possible abolition of laws criminalising abortion… has not been undertaken” in Northern Ireland ( 14 ). This further demonstrates the open gap in care quality between women in Northern Ireland, and other UK residents.

Another major actor in the debate on abortion in Northern Ireland is Amnesty International. They launched a campaign this year advocating for, and promoting, greater reproductive rights and access to abortion services in Northern Ireland. A great deal of statistics and data has been provided by this report, and this essay makes use of this evidence. It must be acknowledged, however, that with the clear pro-choice standpoint of the campaign, there is a risk of bias when using it as a principal source ( 8 ).

Another major reason why women may not be able to travel to access reproductive healthcare is because of the associated stigma in Northern Ireland. Legislation making abortion illegal makes it clear that abortion is frowned upon by the state, supposedly representing public opinion. The heavy influence of the Church in Northern Ireland can also make it difficult for women of a Christian, or other practising religious background, to be free of judgement should they seek out an abortion ( 8 ). Women under the age of 16 may require the support of a guardian – financially, medically, legally and pastorally – if they wish to travel to undergo an abortion. Without the support of family it would be understandably difficult for some. In 1999/2000 statistics showed that the weight of public opinion was anti-abortion ( 15 ). In recent times this appears to have shifted to a more liberal standpoint with up to 70% of people supporting a loosening of the current laws ( 13 , 16 ). That said, there may be scope in the future for the incorporation of sexual crime and fatal foetal abnormalities as legally justifiable reasons for an abortion.

There is also some controversy regarding reproductive education, which may be contributing to the presence of stigma. The majority of Northern Irish schools are of a Protestant or Catholic denomination ( 17 ) – and sexual and reproductive education can be taught from a religious standpoint ( 18 ). Without guidance on the matter it may be harder for young people to access clear information on contraception and safe sex – which may even contribute to the number of young girls seeking abortions. Also, up to 70% of schools have a group called “Love for Life” giving talks in schools ( 19 ). This is a pro-life organisation and actively promotes an anti-abortion viewpoint. Many would argue that this is “brainwashing” children – even those from a non-religious background by influencing them at a time when they are more likely to absorb what they are being told.

In conclusion, it is unlikely that the debate on abortion in Northern Ireland will soon reach a conclusion as there is still significant political and religious unrest in the country. What is clear is that for women and medical practitioners to feel safe having or performing treatment under the current law there must be some clarification on its interpretation in practice. Increased pressure to release the official guidelines is, therefore, a matter of priority. In addition, the recent ruling that Northern Irish women must pay for abortion services in England means that there is significant health inequity between those who have the money to travel and pay for private care and those that do not. This is further compounded by the difficulty some women face when trying to access services abroad when they suffer social stigma and pressure. This means that women may not be able to make their own decisions regarding their own health as they cannot self-fund or support themselves through an abortion process. For this inequity to be addressed in any real sense, it is imperative that Stormont and Westminster look again at this issue and either make treatment free through the mainland NHS, subsidise women’s costs of travel and treatment, or change the law such that women are able to access abortion and reproductive services more readily. The stigma which unpins the inaction on aforementioned decisive policy changes can partly be attributed to the pervasive influence of the church, a deep-set culture of social conservatism and a continued lack of teaching in sexual and reproductive health with an emphasis on pro-life attitudes. Through addressing these factors at a grass-roots level, it may be possible, in time, for Northern Ireland to bring itself back into line with the rest of the UK on this issue and ensure equity for women’s reproductive rights.

Notes

[1] Funding: None.

[2] Competing interests: The author completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available upon request from the corresponding author), and declares no conflict of interest.

References

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