Impact case study database

Abortion is a significant societal challenge: there are 22 million unsafe abortions each year. The World Health Organization (WHO) estimates these have direct and long-term impacts on the maternal mortality and morbidity of five million women and girls annually. The United Nations also prioritises ‘Ensuring universal access to sexual and reproductive health and reproductive rights’ in its Sustainable Development Goals (SDG5.6) and its Women, Peace and Security Agenda. However, governments (including Ireland and the UK) tend to frame abortion access as a mainly legal issue. Liberalising abortion law is equated with the answer to problems of abortion access. Duffy’s research has supported the efforts of those working to monitor and protect abortion access internationally by underlining, through empirical evidence, that law is just one barrier to care. Cost, location, information flow and willingness of health professionals are equally significant in the lived experience of abortion access. NGOs have used this research to support and achieve change.

Public policy:

Until May 2018, abortion was only permitted in the Republic of Ireland (RoI) if the woman’s life was at risk, due to the constitutional recognition of the ‘right to life’ of the unborn (Article 40.3.3 of the 8^th Amendment). This led many women, including those who were raped or carrying foetuses with abnormalities, to use unsafe abortion methods or travel to the UK to access abortion services. Duffy’s research showed an average of two women a day travelled to England at significant personal and financial cost. Campaigning for liberalisation of abortion law led to a Citizens’ Assembly on Repealing the 8th Amendment (2016).

Duffy and Pierson made a submission to the Assembly on behalf of Manchester Metropolitan University, which drew on their Wellcome-funded research. The Irish Family Planning Association (IFPA) - the leading provider of sexual and reproductive health services in RoI – also referenced Duffy and Pierson’s research, multiple times, to support their case for repeal. IFPA was one of just 17 advocacy groups that the Assembly chose to hear from, in person, from over 13,000 submissions. They drew on the research findings to argue that: ‘ Constitutional clauses on abortion force policy-makers, doctors and politicians to view abortion within a uniquely legal framework and impede doctors’ use of clinical judgement’. They also asserted the research, ‘ clearly establishes that the harms of the amendment are such that it may be considered an inherent clinical risk to the safety of women who travel from Ireland for abortions.’ The IFPA later presented its case to the cross-party Oireachtas Committee, which was set up to consider the Assembly’s report. This process led to the decision to hold a popular referendum on abortion and the amendment was repealed on 20^th December 2018, legalising abortion up to 12 weeks in all circumstances and up to 20 weeks where there was evidence of harm to the mother and/or that the baby would not survive over 28 days post-partum. Abortion services were finally introduced on 1st January 2019, after thirty years’ prohibition [A].

Duffy submitted evidence, based on her evaluation of barriers to abortion access, to the Women and Equalities Committee Inquiry (2019) on Abortion Law in Northern Ireland. Her submission was integrated into the resultant report and cited twice: to evidence conflicts between guidance on abortion and doctors’ duty of care towards their patient, and the fear this lack of clarity creates. The Committee used the report to justify widening access to abortion services. Services to provide abortion care were commissioned in 2019 as a result of the Committee’s efforts (although these have been affected by Covid-19) [B].

Public services:

Whilst over 6,500 women accessed abortion in RoI in 2019, doctors, legal experts and charities raised concerns about the ongoing impact of systemic and persistent barriers post-legalisation. Three organisations are now undertaking large-scale evaluations of the new services in RoI to monitor delivery, and to address these concerns. The evidence produced will be submitted to a major review of the implementation of abortion services in RoI, scheduled for late 2021. Evaluations of sexual and reproductive health care within health systems usually use research undertaken by policy-makers focused on external barriers (for example, legal prohibitions). They largely ignore barriers within systems and the perspectives of, and evidence from, grassroots organisations. However, Duffy’s research-informed training, workshops and collaborations with transnational organisations have led to the adoption and implementation of her model in two of the three evaluations.

Abortion Rights Campaign (ARC) evaluation: As Duffy’s research showed, health systems and processes can prevent people from accessing care even when legal barriers are removed. ARC - the largest pro-choice organisation in RoI - wanted to undertake research on abortion experiences under the new system to identify those barriers and help them to address them. They also wanted to highlight the fact that they were most problematic for marginalised and socially-disadvantaged groups. ARC invited Duffy to deliver a workshop on evaluation and to create a tool they could use to gather and systematise their evidence, drawing on her research. She also recorded a podcast for use in further training. ARC say the workshop: ‘ evoked questions that had not yet been considered and provided insight into the key questions to be included to create a robust evaluation’ and that it: ‘ helped to clarify our own evaluative framework’. This ensured they gather evidence that will help them to propose policy change, determine resource provision and identify areas for further research. ARC launched their evaluation in 11 languages in September 2020 to: ‘ gather evidence around how the current legislation is working, from the perspective of those directly affected by it’. It forms a central part of their #Resolvetogetinvolved and #RepealReview campaigns, which emphasise systemic barriers and lived experience [C].

The World Health Organisation (WHO) evaluation: In 2020, WHO also launched an evaluation: “ to provide a better understanding of the barriers and facilitators to the implementation process” for abortion services in RoI. WHO invited Duffy to be the Co-Investigator on its United Nations’ Human Reproduction Programme (HRP) team due to her research expertise, leading the information analysis and sharing her knowledge of the factors that shape women’s access to, and experiences of, abortion services. The study includes collaborators from Global Doctors for Choice - an international network of physicians advocating for access to safe, reproductive health care for all. Duffy produced two reports for WHO, which will also be released as standalone reports in the public domain on the project’s conclusion. The first report, completed in September 2020, presents available quantitative evidence on access to abortion in Ireland - both under and outside of the Health Act - and abortion travel. Her second report (November 2020), presented findings and analysis from the review of information available to health professionals and abortion seekers in RoI. The Principal Investigator states that Duffy also ‘ made valuable contributions’ to the stakeholder mapping process, input on the team’s semi-structured interview guides before they began to collect qualitative data, and input on the analysis, organisation, and dissemination of the study. In addition to adding to the evidence base for the legislative review in Ireland, the study will inform WHO’s wider, international strategy on abortion legislation and service implementation. Translating her research into practice, Duffy has ensured that internal barriers and lived experience are at the centre of the evidence-base that underpins the project’s recommendations [D].

Although the dominance of conservative voices makes policy change difficult in many countries, Duffy’s research has provided an important counterbalance in political debate on abortion and sexual health. In 2006, a legal challenge to the Colombian constitution liberalised abortion access up to 22 weeks in specific circumstances. However, as campaigning groups, such as La Mesa por La Vida, the Centre for Reproductive Rights and Women’s Link Worldwide have highlighted, this change left the systemic barriers that inhibit access in place: barriers they have found it difficult to get addressed. In 2018, Women’s Link Worldwide submitted a legal challenge to the Conservative Government’s efforts to reduce the gestational limit on access to 15 weeks, which they described as: ‘ a serious rollback for women's sexual and reproductive rights’. The fact that women whose pregnancies were over 15 weeks faced the most acute systemic barriers was central to their case. This challenge used a briefing written by Duffy, Dr Megan Daigle (Overseas Development Institute) and Diana López Castañeda (Gender Associations) as supporting evidence (in an amicus curiae “friend of the court” statement). The brief embedded Duffy’s research on persistent barriers to access to abortion services in its defence [E]. They were successful, and in October 2018, the Colombian Constitutional Court reaffirmed the right to abortion up to 22 weeks. This ensured women who meet the legal criteria can continue to access abortion between 15 and 22 weeks gestation, preventing a change that would impact millions. Writing to thank Duffy, Daigle and Castañeda, the senior attorney explained:

The Court issued that these barriers are a form of violence against women and girls, which is a new and important standard. Additionally, this case has strengthen the case-law that guarantees the right to abortion in Colombia. This victory for our movement was possible thanks to the important support that we got through the amicus we sent to the Constitutional Court, including yours [F].

The challenge was just one step in a wider campaign, and 2020 saw the launch of the Causa Justa movement - a collective of over 45 human rights and women’s organisations and activists, health service providers and researchers. In September that year, they launched a lawsuit that aimed at total decriminalisation of abortion in Colombia. The campaign also used a brief by Duffy, Daigle and López Castañeda (submitted as an amicus curiae) to support the lawsuit, again using Duffy’s research on barriers to access and information to underpin their case [G]. Although the decision will not be made until May 2021, Causa Justa contend that the amicus curiae briefings - ‘ really made a difference’ and ‘ are certainly a key contribution to a favorable ruling’. As news provider La Silla Vacia observed, 90% of the 90 research-based submissions supported decriminalisation and, although not binding, ‘ provide arguments that the rapporteur magistrate, Antonio José Lizarazo, must consider’ [H].