Professor Veronica O'Keane:

-----the option of legal abortion was available. This point was made again in a very impressive meta-analysis published by the Academy of Medical Royal Colleges in London. It showed that the academic literature only reflects findings where abortion services are available. There are no scientific studies from OECD countries on mental health outcomes where women could be forced to go through with an unwanted pregnancy. We are talking about high risks of depression in countries where women have the option of legal abortion.

The difference between Ireland and other OECD countries is a woman's only option to obtain an abortion here is to travel. Access to this service is facilitated by State funded information services. A service based in another jurisdiction clearly has inherent problems that will affect the mental health of the woman. There will always be women who will be unable to travel for an abortion. The situation with the migrant women who are unable to travel has been very painfully laid out by the case of Miss Y. I have seen women in my own practice who were unable to travel because of hostility from abusive partners or threats from their community where abortion is unacceptable, culturally.

The category of women who are too sick to travel also includes women who have debilitating mental illness. I have patients who are too sick to travel to an outpatient clinic without being accompanied by a community psychiatric nurse. Many of these women have never travelled outside of Dublin. It would be way beyond their capacity or personal resources to travel to the UK. Neither would they have the capacity to source the abortion pills nor would any of the mental health workers be able to facilitate them in doing so because it is obviously a crime. Women with a handicap such as this need to be compassionately cared for in settings appropriate to their high needs.

The second problem about having a de factoUK-based service is one that every Irish woman or girl who travels bears. The UK path to abortion is a sad and shameful one that Irish women have endured for five decades and it is damaging to women's mental health. It is filled with shame and humiliation. The girl or woman is easily identified and sees herself as being easily identified. What should be a private and sensitively conducted procedure becomes a public journey.

At the heart of the problem of abortion in Ireland is one issue - unwanted pregnancies. It is self-evident that there will always be unwanted pregnancies. There always have been and there will always be a requirement for abortion. The mental health arguments for decent abortion services apply not just to the women who need abortion care. I would go further and say that the mental health of everybody in Ireland is being damaged by the eighth amendment because we are all shamed by the current situation.

To conclude, the recommendations of the Citizens' Assembly are a welcome departure from the dualism of physical versus mental health in its recognition that mental well-being is inseparable from physical well-being. This is particularly relevant in pregnancy where high levels of emotional vulnerability are inseparable from the physiology of the pregnancy. The recommendation that all facets of mental well-being, from suicide risk to damage to mental health, be considered as grounds for abortion takes into account the complexity of each individual woman's psychological experience of an unwanted pregnancy and the unpredictability of risk. The rigidity of constitutional absolutes is the polar opposite of what we need to deal with the needs or pregnant women who have unwanted pregnancies. I think a solution-based compassionate response to this problem will require the removal of the prohibition on abortion from the Constitution. I agree with the recommendation made by the Citizens' Assembly that a legal framework that allows for the unpredictability of obstetric and psychiatric risk should be put in place. A mental health service needs to be embedded within future abortion care because of the complexity of the emotional issues that are frequently experienced in unwanted pregnancies.

The constitutional ban and the consequent rigid legal restrictions in Ireland can escalate psychiatric risk. The constitutional vice-grip and the legal complexities that have followed makes the mental health care of women within unwanted pregnancies unpredictable and is an obstacle to care.