Risks to Mental Health of Pregnant Women: Professor Veronica O'Keane

Before we begin our first session, members and those in the Visitors Gallery are reminded, at the request of the broadcasting and recording services, to ensure their mobile phones are turned off completely for the duration of the meeting.

By virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if they are directed by it to cease giving evidence on a particular matter and continue to so do, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or an entity by name or in such a way as to make him, her or it identifiable.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official, either by name or in such a way as to make him or her identifiable.

I welcome Professor Veronica O'Keane, professor of psychiatry at Trinity College Dublin and consultant psychiatrist at Tallaght hospital, and invite her to make her presentation.

Professor Veronica O'Keane

I thank the Chairman and members of the committee for inviting me. I hope I can be of help to them in their task of interpreting the findings of the Citizens' Assembly. I have been asked specifically to give my opinion as an expert in the field of mental health. My current role is a joint academic and clinical one, as consultant psychiatrist in the service of the HSE at Tallaght hospital and professor of clinical psychiatry at Trinity College Dublin where I lead a research programme in perinatal psychiatry. My previous experience includes leading a national perinatal psychiatry service in London for five years at the Maudsley Hospital which covered all of the United Kingdom. Concurrently with that position, I was head of the perinatal psychiatry section at King's College GKT School of Medical Education where I led a research programme in perinatal depression. I have had papers published in the scientific literature on the subject of perinatal depression and written a book on the topic. I co-authored the standard clinical assessment tool for perinatal psychiatry disorder in the United Kingdom and served as an expert for the National Institute for Clinical Excellence in devising guidelines for clinicians on the management of perinatal depression. I set up two hospital psychiatry services, including the suicide prevention service in Beaumont Hospital. I was an expert witness at the two Oireachtas hearings which led to the introduction of the Protection of Life During Pregnancy Act and was also privileged to serve as an expert witness at the Citizens' Assembly. Last March I co-hosted, with the National Women's Council of Ireland, the World Congress on Women's Mental Health at the RDS in Dublin.

I begin by thanking the members of the Citizens' Assembly for their work. The process and governance of the assembly in its consideration of the eighth amendment were an example of the best of democratic principles in action. Its conclusions were solution-focused and not ideologically driven. Most of the recommendations made are relevant to mental health, but they have been spelled out in a very helpful way that leaves no room for ambiguity. That clarity is one of the strengths of the document. A majority of the citizens recommended 12 reasons for which termination of a pregnancy should be lawful in Ireland. For each general health reason listed, a parallel mental health reason was given. For example, where 99% voted that abortion should be lawful when there was a real and substantial risk to the life of a woman, 95% voted the same where there was a real and substantial risk to the life of the woman by suicide. Similarly, 93% and 90%, respectively, of the citizens supported abortion where there was a serious risk to the physical health of a woman and a serious risk to her mental health. The same applied to a risk, as opposed to a serious risk, to physical health and mental health, with 79% and 78%, respectively, voting that abortion should be available to women in these circumstances.

There are two particular points I wish to highlight in respect of the assembly's recommendations. The first is that, as I have outlined, support levels for the provision of abortion care for medical and mental health reasons were very similar. In fact, 72% of members recommended that a distinction should not be drawn between the physical and mental health of women. That recommendation was an enormous relief to me and my colleagues. The mind-body dualism division has plagued our society and created much unnecessary suffering, leading to stigmatisation of and discrimination towards those who suffer with psychiatric disorders. Separation of mental health from physical health has been at the heart of the debate about abortion for the past three decades, following on from the 1992 ruling in the X case that suicide risk constituted grounds for an abortion. We have had two referendums, in 1992 and 2002, where suicide was upheld by a majority of voters as a legitimate reason for an abortion. We had a very difficult debate on the suicide provision leading up to the enactment of the Protection of Life During Pregnancy Bill in 2012 and 2013. It is now recognised in law that suicide constitutes a risk to the life of the woman in the circumstances of an unwanted pregnancy. The Citizens' Assembly understood there was no distinction between physical and mental health and made its understanding explicit. The importance of that recommendation cannot be underestimated and changes everything.

I will comment briefly on dualism which has been a very destructive force in society's understanding of health. It might seem evident, but it is important to point out that the brain controls the body. While one may feel sad in one's heart or anxious in one's gut, these feelings are directed from the brain. The dialogue between the body and the brain is never stronger than during pregnancy because the pregnant uterus produces hormones which cross into the pregnant woman's brain and modify the emotional brain. Emotional changes also occur because pregnancy is very challenging and parenthood is probably the most serious challenge any of us will face in our lifetimes.

My research group has looked at rates of depression during pregnancy, the first such study to be conducted in Irish maternity hospitals. We found rates of 16%, which is slightly higher than EU norms. Being depressed when pregnant is a very serious problem. Not only is the woman intensely distressed, but the stress hormones alter the baby's physiology such that the foetus is growing in a high-stress milieu and at increased risk of being born earlier and with obstetric problems. Depressed pregnant women are often unable to attend to their own needs and do not present as regularly for outpatient appointments as non-depressed women. Infants born to women who are depressed during pregnancy are more likely to suffer from childhood learning and behavioural problems and depression in early adulthood. All of this demonstrates that the emotional brain is important not just to the general well-being of the pregnant woman but also to the subsequent health of her baby and that baby's trajectory throughout life. The treatment of psychiatric disorders in pregnancy is seen as a priority for this reason.

An unplanned or unwanted pregnancy increases the risk of depression during pregnancy.

A US study of more than 100,000 women was published earlier this year. The study examined the relationship between unwanted pregnancy and perinatal depression. The study showed that an unwanted pregnancy increased the rates of perinatal depression by 50%. It must be said that in this study, as in all other published studies from OECD countries, the option of legal abortion was available for these women.

Excuse me for interrupting, Professor O'Keane, but there is a phone interfering with her microphone. Does she have a phone on her person, in her handbag or near her?

Professor Veronica O'Keane

I have but it is switched off.

Is it completely switched off? Airplane mode should be fine. I ask her to please check.

Professor Veronica O'Keane

Shall I put it somewhere else?

Yes. Broadcasting can let us know if that does not work. Interference makes it difficult for people to report the debate and interferes with television coverage.

Professor Veronica O'Keane

Is that any better?

Does Professor O'Keane have a tablet, an iPad, computer or anything else?

Professor Veronica O'Keane

No.

Is Deputy Mattie McMcGrath's phone switched off as well? Yes. Let us continue.

Professor Veronica O'Keane

Who cannot hear me?

The people who report the debate and the broadcast unit which provides television coverage.

Professor Veronica O'Keane

I was talking about unplanned pregnancies in a US study on more than 100,000 women. The study showed that perinatal depressions increased by 50%.

My last point was that-----

I am sorry for interrupting.

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 facto UK-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.

I thank the professor and apologise for the interruptions. We appreciate her contribution.

There are four lead speakers on my list today and they are Deputies Kelleher, O'Reilly, O'Connell and Coppinger. I ask them to indicate how much time they require.

Deputy Browne has indicated that he will commence. Does he wish to spend most of his time posing questions to this witness? Shall I tell him when five minutes have elapsed?

I will ask a couple of questions first.

I will let him know how much time he has left over.

Yes. I thank the professor for being here. She is very welcome. I very much echo her welcome for the belated recognition that there should be no distinction between physical and mental health. I think it is very important, whatever decisions are made, that no distinction is made between the two of those.

In terms of Professor O'Keane's role as a consultant psychiatrist and the impact of the Protection of Life During Pregnancy Act 2013, has its application been effective or non-effective in practice?

Professor Veronica O'Keane

In terms of practice, my view is that the majority of women who are suicidal because of an unwanted pregnancy are still travelling. I do not think we are treating the women who are suicidal, because of unwanted pregnancies, in Ireland. I think we are treating the women who are suicidal with unwanted pregnancies, who are unable to travel, in Ireland.

So far, seven women, theoretically, have had their lives save by the legislation. Obviously that is a very good thing in itself. It is a very good thing that we have legislation that will save women's lives if their lives are at risk because of being pregnant. In that sense the legislation has worked. It is very clumsy legislation and the majority of my colleagues feel very uncomfortable with trying to work within this legislation. It is very difficult for women. As most people here probably know, three specialist assessments are required. The legislation also requires that the woman would go to a GP or an accident and emergency doctor who would initially refer her. In order to have a legal abortion because of a risk of suicide a woman must see a minimum of five doctors. If one of those doctors is unwilling to see her the process is clearly lengthened and that has happened quite a lot with this legislation.

Colleagues feel uncomfortable with the legislation and do not want to deal with the matter. A woman who has been referred by a GP or an accident and emergency department presents to the doctors. The first person may say, "I am not comfortable with this, call me a conscientious objector". He or she rings up his or her clinical director who also says: "Call me a conscientious objector, I am not comfortable with this legislation."

The clinical director then rings another colleague. It may escalate to a national level and a psychiatrist from a national panel might have to be called. There is usually a period of delay in which the woman does not know what is happening because no one knows what is happening. She may then see someone who does not believe that she fulfils the criteria, so the process must restart. It is distressing for a woman who is feeling suicidal, is pregnant and is highly vulnerable to have to repeat her story to everyone. Every time she tells the story, it is an emotional journey that takes an emotional toll on her, and she is someone who is suicidal. In my practice, I try to minimise the number of people to whom my sick patients have to talk. If a patient has already been clerked in an accident and emergency department, I will see him or her next and say that the patient does not need to be clerked again in a ward. The repetitive intrusion into a patient's extremely private crisis is counter to good sensitive practice.

Is there an indication of how long the delay is? In an acute situation, what is the typical period?

Professor Veronica O'Keane

I am not privy to that information, so I will discuss my experience in a general way. The delays have been unacceptable. There have been delays of up to two weeks where each day is a nightmare for the woman. Sometimes, she has been hiding this fact from everyone, including her partner or ex-partner and her children. Most of the women I have seen in this regard have been mothers and have been trying to pretend that this is not happening to them. They are not given any reassurance about whether it will happen. They are usually financially destitute, but are unable to look for money because they must hide the fact that they are seeking an abortion. I cannot say what the time lapse is generally, but it has been unacceptable in the cases that I have seen.

Another issue that is worrying about the Protection of Life During Pregnancy Act is that while we have a register of women who have had the procedure, we have no idea of the number of women who have applied for abortions. There may be women who applied for abortions and were not certified as being appropriate for same and - I say this with trepidation and a great deal of sadness - who have not survived from a psychiatric point of view or have gone on to kill themselves. I do not know - nobody knows - because there is no register of women who apply for the procedure. There is only a register of women who have received it.

I thank Professor O'Keane. Her last comment answered what was going to be my next question.

Professor O'Keane stated that we needed a solution to the real life problem of unwanted pregnancies and not a moral, ethical, metaphysical or philosophical discussion about abortion. Will she expand on that?

Professor Veronica O'Keane

People want a solution to this problem. They do not want to discuss any more the metaphysical issues that have dominated the debates or the hypothetical situations of if this or that happens. People understand that there is a real problem that has been festering for a long time. They understand that we need a solution to it. At this point, the ethical issues need to be driven by the need of women with unwanted pregnancies rather than by metaphysical philosophical discussions.

I call Deputy O'Reilly next.

The Chair might tip me off at the five minute mark so that I can do half and half.

I thank Professor O'Keane for attending and for her presentation, which cleared up many issues, particularly regarding the Protection of Life During Pregnancy Act and its practical or impractical operation, whichever the case may be. There is an imposition on women. The fact that there is no register of those who applied and, dare I use the word, were unsuccessful in their applications is remiss of us because we cannot get a clear picture of how the legislation operates other than through the evidence that Professor O'Keane has given us, which is that the Act often leaves a woman in acute distress for up to two weeks while colleagues await a decision. That is most unfortunate, but it is welcome that this information is now in the public domain.

Professor O'Keane might address two points. First, it is clear from her opening statement but, in her opinion, are her pregnant patients who require psychiatric care more at risk of suffering physical ill health as a result of their mental ill health? The two are inextricably linked. Maybe Professor O'Keane might expand on that point.

Second is a point that we should probably be addressing in every session. There is an argument that, in the event of us making a change, be it large or small, to the level of access that Irish women have to abortion care, we will somehow be opening floodgates and there will be a dramatic increase. From Professor O'Keane's experience, will she give us an indication of what the likely implications will be in that regard?

Professor Veronica O'Keane

I will start with the Deputy's second question on floodgates. I do not understand the floodgate phenomenon. A good presentation made to the committee earlier showed that the rate of abortion had been steady over the years, although I hope that it will decline slightly with better contraceptive care. The availability of abortion pills on the web has increased and the rate of travel for surgical abortions has reduced. The floodgates are open and always have been. They have only been pointed towards the UK. We have a de facto abortion service. It is just not in our own country. I cannot see making abortion legal in Ireland changing the number of women having abortions. Rather, I hope that, by having a better health service that is more women focused, inclusive, sensitive and compassionate, we will reduce the number of unwanted pregnancies and improve our care for women with unwanted pregnancies. At the heart of this matter is giving care to women who have unwanted pregnancies.

The Deputy's other question was on whether a woman who was depressed would be at an increased risk of developing obstetric problems or other physical ill health. That is definitely true. If one is depressed in any circumstance in life, one is at greater risk of becoming medically unwell. That is because our stress system is controlled in our brain. It is the control station for the secretion of our stress hormones. If I am stressed, my brain tells my adrenal glands to secrete cortisol. Being in a stressed condition for a long period of time is damaging physiologically. It has been shown to lead to cancers, heart disease, lung disease and osteoporosis. Every physiological system is sensitive to stress hormones, particularly long-term exposure. During pregnancy, there is a rapidly developing foetal system. It will of course be sensitive to stress hormones.

If we are thinking about abortion care, we should be thinking about it in the care of the general mental health of pregnant women, and as I stated previously, specifically in the area of unwanted pregnancies. "Yes", is the answer. Are specific disorders that are specific to pregnancy, such as pre eclampsia, Caesarian section and obstetric complications, more likely during pregnancy if a woman is depressed? "Yes" is the answer. Being depressed disadvantages the woman and the foetus, and the delivery of the foetus into the world.

I thank Professor O'Keane for coming in today.

There are just a couple of things I want to touch on. Professor O'Keane's presentation was very helpful.

On this division of mind and body health which Professor O'Keane referred to as dualism, and which she stated today is found by the Citizens' Assembly to be the entirely wrong approach, she quotes a study showing that, according to her statement: "Pregnancy is associated with increases in anxiety and depressive symptoms and is the highest risk period in a woman's life for depression." The following are three questions around that whole concept. Is an unplanned or forced pregnancy a threat to the short and long-term mental health of the woman carrying it and can it cause mental harm to others around her? When a couple - two people together - are challenged by an unplanned or unexpected pregnancy, what effects does this pregnancy have upon the mental health of the man? When a couple seek a termination together, is there any evidence that the male partner can suffer from mental health challenges, such as stress, depression, guilt, shame and emotional pain also? Has Professor O'Keane any experience with the effects on the men in the situation?

I am conscious that some people are trying to shut down a debate regarding mental health grounds by proclaiming that abortion is not a solution for suicidal ideation. Would Professor O'Keane agree that, while the act of administering an abortion may not per se be a solution, circumstances can differ from woman to woman and the option to access an early termination is far more likely to result in better outcomes for the mental health of the woman and her partner?

In Professor O'Keane's professional opinion, should mentally-ill pregnant women who do not want to be pregnant be subject to internment until they have delivered a child and would this be harmful to their mental health? Are Ireland's laws acceptable to retain without alteration? Do they adequately assist women who are too poor to travel for a termination who may be immigrants without papers - Professor O'Keane spoke about women with diminished mental and physical capacity - or women who are psychiatrically unwell to the point of psychosis, delusion or catatonia? What did we do in the past and what do we do currently with poor people, mentally unwell people or those with diminished capacity? What I am trying to get at here is what Professor O'Keane spoke about in her statement. Who is left behind? Really, that is what I am getting at here. I would ask Professor O'Keane to elaborate on some of that in her professional capacity.

Professor Veronica O'Keane

I thank Deputy O'Connell. There are quite a few questions in that. I will start again at the end because of my short attention span.

The Deputy talked about the vulnerable women who were unable to travel. If I had to pick the worst situations that arise from our current situation in relation to an absence of a proper abortion service it would be those of the women who are left behind. It is the women who sometimes do not have the education to understand how to access resources. They do not have the confidence to go to professionals. They do not have the knowledge to access the professionals and they do not have the confidence to talk to those professionals about what they might want. They may be ashamed of what they want. They may be in a terrible state of conflict about it. They may want an abortion and not be able to put words on it. There are as many extremely sad situations as there are women pregnant who are left behind in that very vulnerable category.

I can only talk about my experience of dealing with very vulnerable women who have very significant mental health disorders. I might be talking about women who may not even understand that they are pregnant for a few months. Perhaps the medication they are on is suppressing their menstruation and they do not have regular cycles, and they may not even be aware. By the time they become aware of the pregnancy, they could be 14 to 16 weeks pregnant. They are unable to process the idea that they have to go for maternity care and their GP will try and sort out their obstetric care, when they go to their GPs. This group of women do not have sensitive, appropriate services that can meet their high needs. These sensitive services are available in other branches of medicine for these women. I have had women who have had breast cancer and they have had really wonderfully appropriately sensitive services, in terms of guiding them through the palliative stage of their care and, indeed, from the palliative stage of their care to their passing. We can only guess about those women. In a sense, I know that group of women are left behind. We should feel ashamed by the fact that these women are ignored and neglected.

In relation to early abortions, obviously, the earlier an abortion, the better it is for the woman. The situation that we have in Ireland delays abortion. I have just told the committee how the Protection of Life During Pregnancy Act 2013 is cumbersome and certainly delays abortions, but travelling also delays abortions because some women do not have passports, some women do not have the finances and some women have not made up their excuses that they are going away with a friend for a weekend for fun in Liverpool or whatever. Obviously, travel takes away a woman's privacy. That is probably one of the worst aspects of it but it also leads to later abortions. It is an established fact that the average age of gestation of Irish women is higher than that of women in the UK.

On unplanned pregnancies, I think the Deputy referred to "unplanned and forced pregnancies". I guess I would see them as being in very different categories.

"Or forced" not "and forced".

Professor Veronica O'Keane

Unplanned pregnancies obviously can become wanted pregnancies and everybody is happy. Of course, unplanned pregnancies can become unwanted pregnancies and as I said, sometimes that is an ambivalent place for a woman to be. Some women will remain ambivalent and they will obviously proceed with the pregnancy, and those women need a lot of support because they are at a very increased risk of developing depression and having complications with parenting.

However, the women who have the unwanted pregnancies who want an abortion can be in a very difficult position because, obviously, they may not be able to travel. We are letting those women down with the current situation here and forcing them to travel; we are putting women who are unable to travel in positions of having pregnancies that are not wanted which leads to children that are not wanted. It is an issue that does not raise its ugly head often, but it does happen. My practice is full of adults who were not wanted as children and that has to be borne in mind.

In terms of forced pregnancies, obviously, it is very important that women who have forced pregnancies have immediate access to abortion care that is sensitive to their situation.

On the mental health of men, in my view men are very traumatised by the situations that their pregnant wives can find themselves in in relation to unwanted pregnancies.

The committee will hear evidence later today from a man, Gerry Edwards, who will be able to tell the committee a lot about it from his point of view.

On abortion and non-foetal anomaly abortion, there is not much literature. I have never seen a man who was traumatised, unwell or presented to me with depression because a partner had an abortion. That is not to say that it is not a problem but it is an area that has not been explored in great detail. Post-partum depression in men has been explored but not post-abortion psychological status.

I have one final question.

That is over ten minutes. If members ask lots of questions, there will be lots of answers.

When the National Association of General Practitioners was before the committee last week or the previous week, the issue of referral was raised. We were told the law effectively precludes a doctor from giving the file of a patient to medics in the UK. The professor has experience as a psychiatrist who often deals with people with very complex psychiatric needs. As a professional at the height of her game, how does Professor O'Keane feel about sending a women away with a file under her arm which might relate to a long and complex psychiatric history? Does she sit in her office feeling stressed over what will happen on the other side? As a medical person and a professional, how does she feel about sending that patient that she has cared for away on her own?

Professor Veronica O'Keane

I do not know if the joint committee is ready to hear that evidence. I will understate it in as appropriate way as I can. I find it extremely distressing. I think it is wrong. It is against all our instincts and training. We do not have a right to express our distress because we are witnessing so much more distress, but it is extremely distressing, very frustrating and very stressful.

I thank the Deputy and Professor O'Keane. Deputy Coppinger has ten minutes.

I thank Professor O'Keane for her presentation. Earlier, she said that people want a solution and that they know we need one. I agree with her, and we need a real solution that deals with the whole issue of abortion in this country. There are ten people who travel daily and the five who we know now are taking abortion pills in their own bedrooms, so that is 15 people a day. Today we are discussing mental health which is critical for all those people, and later we will discuss rape and fatal foetal abnormality, which probably accounts for about 6%, and is a small minority among the reasons people have abortions. The evidence this committee has heard over recent weeks has been resounding regarding the need for abortion legislation which deals with the reality of all those people, the 92% who fall under the abortion under 12 weeks, on request, which is just one recommendation of the Citizens' Assembly which could deal with this entire issue. It relates to a previous decision in private session not to delay or put back a decision to repeal the eight amendment.

I want to make a point on that because it is a cause for concern that if people who believe in repeal are not willing to make a decision on the matter now, it suggests that later in the process, they may only give their vote for repeal if it is based on conditions being attached. According to a report in The Irish Times at the weekend, we learned that despite being told that every member of this committee has freedom of conscience to vote as they wish, party head offices will not allow abortion legislation which will deal with anything beyond rape and fatal foetal abnormality and possibly serious risk to health-----

It is difficult for the witness to comment on those.

I am making those points because we agreed-----

I have allowed the Deputy significant latitude

We agreed that matters taken in private session can be brought out in public in order that the public knows what is going on.

They could have gone into public session.

I will finish on that. Some of my questions relate to abortion pills, which have changed attitudes towards abortion in this country. It is inevitable that eventually, no matter what happens on this committee, that will continue to be normalised here.

The mental health of all women who want abortions matters, and of course this is the case for women who are suicidal. Is it the case that suicide is the leading cause of direct maternal death in Ireland? In Professor O'Keane's statement, she noted that pregnancy should be a time of great joy, which is how it is often portrayed, but it is also the time when women are most likely to suffer from depression. In her presentation, Professor O'Keane noted the link where the lower a person's socio-economic status and lack of support, the higher the rate of depression. Will she expand on this? Does she think that these are some of the reasons women choose abortion?

Professor Veronica O'Keane

On the Deputy's remarks about exceptions-based legislation, there is something that is probably relevant. If the committee decides to go down a route of recommending an exceptions-based legislation, that will continue and propagate the same problems with which we have been continually dealing. With constitutional restrictions determining the law that will determine clinical practice, there is a lack of flexibility. Medical and psychiatric work is absolutely unpredictable. There could be a woman who says that she wants to have an abortion, that she wants to end the pregnancy, and then she meets a doctor who tells her that she cannot do that in this country, that they are sorry and that they will deal with it as compassionately as they can. That woman could become suicidal. Risk fluctuates very quickly. To enact legislation within a constitutional vice grip of a ban on abortion is extremely difficult.

I want to read something to the committee relating to that because it is very important, if that is okay.

Professor Veronica O'Keane

I do not know if this has been brought to the committee's attention. These are the official guidelines from the Department of Health for the implementation of the Protection of Life During Pregnancy Act 2013. If we go to page 1, the second paragraph begins as follows:

The Protection of Life During Pregnancy Act 2013 was enacted in July 2013 and commenced in January 2014. The purpose of this Act is to restate the general prohibition on abortion in Ireland while regulating access to lawful termination of pregnancy in accordance with the X case and the judgment in the European Court of Human Right in the A, B and C v Ireland case.

The Act achieves this objective in the following ways:

- by providing a clear criminal prohibition on abortion.

These are the guidelines for doctors, on the first page. Any sort of legislation within an unyielding constitutional framework will not be appropriate to the sort of medical care that is practised. It does not allow for unforeseeable circumstances. Good care cannot be dictated by exceptions.

It just cannot be done. If we decided to restrict to rape, for example, would we then have to prove that every woman had been raped? What is rape? The whole thing would be very difficult. I do not know if that is any help in answering what problems could arise from replacing as opposed to repealing the eighth amendment. Medics need the eighth amendment to be repealed in order to have a free field in which we can create a legislative framework to provide the flexibility of care that is necessary in medicine to manage women in these very difficult situations.

In another study that Professor O'Keane did about the prevalence of rates of antenatal depression in the Irish obstetric service - it has a very long title but she knows the one I mean - she found that one in six pregnant women was depressed, which seems to be a higher rate than in other countries in the OECD. The depression got worse as the pregnancy advanced by trimester and depression was higher among poorer women with less support, issues of domestic violence and also among younger women. Does that suggest to Professor O'Keane that the stress of being pregnant is exacerbated by the illegality of abortion in Ireland?

Professor Veronica O'Keane

That is the only study that has ever been done among pregnant Irish women. I cannot say that because I did not ask that question, but it is a sad fact that our rates of antenatal depression are higher than in other European countries, or at least that is what our research has indicated. In response to what I think Deputy Coppinger is asking, which relates to her previous point about lower socioeconomic status and socioeconomic disadvantage, rates of depression are higher and rates of unwanted pregnancy are higher in women who are socio-economically disadvantaged. When we are looking at depression and abortion needs, we are talking about the most vulnerable people. When we are looking at people who cannot travel, we are talking about the same group of marginalised very vulnerable people. They are the people we are turning our backs on. I do think we are also treating women who have the means in a very shoddy and humiliating way, but the women who bear the brunt of the constitutional ban on abortion here are the very vulnerable women.

In relation to the study, it could be interpreted that the lack of abortion in this country or the fact that our services are de facto in another jurisdiction does lead to higher rates of unwanted pregnancies and therefore higher rates of depression, but it could also be that our perinatal psychiatry services are very underdeveloped. I know that Dr. Anthony McCarthy is coming here in the near future to give evidence in relation to that because he works directly within that service, so I will leave that to him. We are woefully under-resourced here. Colleagues from around the world are gobsmacked at the situation. When they came to the conference in March they were absolutely amazed at the lack of health care services in perinatal psychiatry in Ireland. I do think the issues are connected. I think perhaps the entire mental health area is a no-go area because we are ignoring a very big problem. Once we allow ourselves to see that there is a need, embrace it and look for pragmatic solutions I think a lot of other services will follow.

I thank Professor O'Keane for her presentation. It is a very important topic that we do not talk much about. She made a comment about the women who are left behind and that got me thinking about the women who cannot travel or who cannot access abortion, who may be in the mental health system for whatever reason in terms of the severity of their condition. Without identifying women, in my career in addiction services I have watched women with dual diagnosis. I remember one woman who wanted to access abortion very early not being able to. She was seen as presenting with addiction not having a dual diagnosis. I remember her just giving up on that. When she did continue with the pregnancy, which she did not want, I watched her fight for a long time through the courts to try to hold on to that child so she was traumatised over and over again for her mental illness. She could not win in any way. Some people have the impression that when pregnancies continue the women are glad that they did and they go off and have normal, happy lives and everything is okay. Could Professor O'Keane comment on the effects on some of those women because of how we have treated people with mental health difficulties in this country? If one has a physical illness such as cancer nobody accuses one of not being able to look after one's children but if one has a mental illness people will assume one is not capable of caring for one's children. What kind of support is there for women in that situation? Without identifying individuals could she refer to some of those women who have found themselves in that situation?

When we looked at the risk to physical health the witnesses who came in were very clear that there is no one moment in time where one can identify, regulate or create legislation for the point at which one becomes a serious risk. Because we are making no distinction between mental and physical illness, does that same principle underpin mental health in the sense that there is no moment in time when one can say a person has gone from being a minor risk to a serious risk?

Professor Veronica O'Keane

Senator Ruane has brought up a number of points. The point about the woman with dual diagnosis should not arise. If somebody is suicidal somebody is suicidal, and if they are suicidal because they are pregnant then the analysis does not have to go below that unless there is a treatable mental disorder which is making them suicidal and is not related to the pregnancy.

Situations are very complicated so I guess third hand information is very difficult to comment on, so I will talk perhaps about my own experience instead of addressing that directly. Some people have very complicated lives. They have complicated lives because they were born into situations of deprivation that are unimaginable to a lot of us. Children are neglected. They are left in dirty nappies. They are not spoken to. Nobody gets them up in the morning or puts them to bed. I have a lot of contact with Tusla because a lot of my patients were brought up like that. Of course they need psychiatric services in adulthood and of course they have difficulties parenting. It begets a cycle. If one does not have control over one's reproductive fertility or whether or not one has children, if one cannot practise responsible parenthood this situation of deprivation is going to continue. I think it is a very important societal point. If one has somebody with dual diagnosis I would say that increases rather than diminishes the risk. On the other hand, if a woman changes her mind during a pregnancy, if she initially has an unwanted pregnancy and then decides it is wanted then that wish should be respected. The same choice that pertains to choosing whether or not to continue with a pregnancy also pertains to whether or not one wants to be a parent, if one continues with a pregnancy, even if one is being forced to continue with the pregnancy. Choice is terribly important. If a woman does want to continue with a pregnancy and she is in dire circumstances, what we need to do as a society and as a medical service is to intervene with all the supports we can muster to help her.

We really try to break the transgenerational transmission of deprivation by targeting young mothers who have children and who want help. It is very satisfying work, because the children benefit from it and the mothers develop great confidence in their own lives and in their abilities to mother. When we are talking about abortion, we are talking about parental care as well, and all those other services. This debate allows us to talk about issues that we could not talk about previously, such as very difficult parenting, children who were perhaps not wanted and became wanted, or children who are simply not wanted whom the State may have to provide for or for whom alternative parents may have to be found. It is a very complex area, but in my experience it is tremendously satisfying, and intervening when families are young to try to help women parents, regardless of whether those children where even considered or ever wanted, can be done. We need that as much as we need abortion services.

Senator O'Connell asked a question about how we treat younger women and girls and whether it would be appropriate to detain them in psychiatric hospitals if they are suicidal because of unwanted pregnancies. I believe that is absolutely and utterly unacceptable. The case of the 15 year old who was detained is unacceptable. I am not talking as a psychiatrist who knows anything about the case. I am talking as a citizen who is observing what has happened. Pregnant women who are suicidal because of their pregnancy should never be locked up and detained, ever. If we are stooping to that level of abandonment and putting girls in captivity who are in desperately complicated and distressing situations emotionally, we really need to look deep into our hearts. We need to move this legislation forward because it is absolutely the wrong way of doing it.

I am trying to manage time for each individual member so I apologise if I intervene to speed things up.

I welcome Professor O'Keane to the committee. I have listened to what she has said. It is important to say at the outset that when it comes to any change to the eighth amendment, the burden of proof is squarely on those who want to see it changed and to show that change would be a good thing.

Professor Veronica O'Keane

I agree with the Deputy.

In order for the pro-choice people to make their case, they need to prove that having an abortion would be a dramatic improvement for the woman. We already know that it would be a bad thing for the baby, because the baby's life would end. There is clearly a huge amount of evidence around the world which shows that there is no real benefit to a woman's mental health from abortion, but there is evidence to show that it can have a detrimental effect on her mental health. People on the pro-choice side of the debate get very defensive in their questioning. They feel as though we cannot ask them to give us evidence on the mental health of a woman. Listening to the pro-choice campaigners, one would get the impression that the evidence shows that abortion is a good thing for the woman. It is not. Why are pro-choice people so defensive when it comes to the lack of evidence, and why do they not want to acknowledge that there is evidence to show that abortion does not benefit a woman's mental health?

Professor Veronica O'Keane

The Deputy said that there is evidence that the mental health of a woman suffers from abortion.

Professor Veronica O'Keane

I would be interested in seeing that evidence.

Dr. David Fergusson has written a book on the topic. Has the witness read his book?

Professor Veronica O'Keane

I am aware of Dr. Fergusson's academic work, and that of Dr. Coleman. They are the two people the Deputy is going to quote.

I have only quoted Dr. Fergusson.

Professor Veronica O'Keane

They are the two studies that people who are opposed to abortion always quote, so it is very easy to predict. There are only two studies. In index No. 3 of my submission there is a document which has been written by the Academy of Medical Royal Colleges, supervised by the National Collaborating Centre for Mental Health. This document looks at literature research which identified almost 9,000 references. The body was composed of individuals hailing from many different disciplines, including obstetricians, psychiatrists and physicians. The conclusions are laid out here. Very interestingly, the Coleman-Fergusson work is specifically cited as being unscientific and not meeting the standards of other work in the area. I am not trying to become the expert here, but I am simply letting the Deputy know that the Fergusson and Coleman work is not up to par. It is not evidence. The evidence is to the contrary, being that abortion does not damage a woman's mental health. I am very happy to send the Deputy more details about that because he seems to be misinformed.

I would appreciate if the witness could read Dr. David Fergusson's book and give us her opinion on it. There are 100,000 people alive in Ireland today because of the eighth amendment.

Professor Veronica O'Keane

Sorry, I do not understand that comment.

Can I finish please?

We will allow the Deputy to finish what he has to say, and the witness can reply.

Professor Veronica O'Keane

I apologise.

There are more than 100,000 people alive in Ireland today because of the eighth amendment. In the UK there are 190,000 abortions every year. Some 98% of those abortions take place on mental health grounds. Has the witness come across Ms Ann Furedi, who is the director of the British Pregnancy Advisory Service?

Professor Veronica O'Keane

In what way? I am aware of her work.

She is the CEO of one of the leading providers of abortion in the UK. She said, "It is not the case that the majority of women seeking abortions are necessarily at risk of damaging their mental health by continuing the pregnancy". This is significant in terms of the law. Women and men in the UK have indicated that this is the law. Will the witness discuss those comments and the current operation of the laws in the UK?

The witness can make the point that she wanted to make a few moments ago and respond to the Deputy's question.

Professor Veronica O'Keane

I am baffled. I do not understand that statistic. I have not met anybody who is able to explain it to me in a way that makes sense to me either. I am going to move on from it. I do not understand where the Deputy found this evidence.

The statistics are there. That is the amount of people who have been saved since 1983.

Professor Veronica O'Keane

I do not understand that. Is the Deputy saying that every abortion that a woman has is potentially a life?

The restrictions in place under the eighth amendment mean that there are roughly 100,000 people alive today. In the UK there are 190,000 abortions every year. That is one in every five children. The director of the British Pregnancy Advisory Service in the UK said that 98% of abortions in the UK are down to mental issues. This lady then said that is not the case. We have good, strict laws in Ireland which have done us no harm over recent years.

The last thing I would do is follow the example set by the UK. Can the witness imagine one in every five pregnancies in Ireland being aborted?

The British advisory service to which the Deputy refers will be giving evidence to the committee in the coming weeks. I will allow Professor O'Keane to respond but time is nearly up so Professor O'Keane and Deputy Fitzpatrick should constrain themselves to a couple of comments each.

Professor Veronica O'Keane

Each?

The witness may comment and if the Deputy wishes to respond, he may.

Professor Veronica O'Keane

That does not seem like a particularly fair division of time. I intend no disrespect but that was more of a speech than a question. I fail to------

The witness has been making speeches all evening.

It often happens in the Oireachtas that people make statements when they should be asking questions. Unfortunately, it is not an unusual phenomenon in these parts. Please continue.

Professor Veronica O'Keane

What the Deputy has referenced is the opposite to evidence. I do not see how a vague and abstract extrapolation such as that amounts to evidence in respect of 100,000 people being alive because of the eighth amendment. As regards whether we want to go down the road the UK has, we have already done so. That is where our abortion service is. Women go to England and that is where our service is provided. I do not know if doctors in Ireland aspire to having a service similar to that available in the UK. We want a solution appropriate to our needs. We want a compassionate, woman-centred service that will address the needs of Irish women. That will inevitably involve a more liberal regime. It is not possible to make flexible legislation within the vice grip of the constitutional prohibition. The amendment did not save lives; it diverted the problem to our neighbours in the UK.

The protection of the eighth amendment has saved the lives of many people in Ireland. The last thing I want to happen is for Ireland to become the UK. I do not want every fifth child to be aborted. We have very safe rules and regulations in this country and I would love to see them protected. There is an onus on the Government to invest far more money in mental health. It has given many commitments in that area. The last thing I want to happen is for abortion to be as freely available in Ireland as it is in the UK.

That is more a comment than a question but the witness may want to briefly respond.

Professor Veronica O'Keane

To our shame, we do not provide abortion care for women here. We are turning our back on women. We have health services but they are in a different jurisdiction and we are turning our back on those women.

There are more witnesses coming before the committee at 4 p.m. and that is why I must be strict on time. I apologise if it seems I am cutting speakers off but there is a difficult process that needs to be managed.

I thank the witness for her paper and her attendance. It has been very interesting. Not a day goes by without committee members learning something. On page 4 of Professor O'Keane's paper it is stated that pregnancy is associated with increases in anxiety and depressive symptoms and is the highest risk period in a woman's life for depression. That claim is referenced and it is a published work but is it the commonly held view? Is there any deviation from that view?

Professor Veronica O'Keane

It is the commonly held view.

I wanted to ensure that is understood. I was interested by the point the witness made in respect of the US study conducted where abortion was available. She said no comparative study has been done in an area where abortion is not available. Along with several other Deputies and Senators, I attended a symposium called by the Ceann Comhairle at the beginning of the Dáil session and one of the issues raised was the deficiency in perinatal care. It was said that suicide, including post-partum suicide, is the number one cause of maternal death. Is there a comparable study on maternal suicide in countries where abortion is not available?

Professor Veronica O'Keane

No.

Professor Veronica O'Keane

There are no such comparable studies. Apart from very small states in Europe, Ireland is the only substantive state that does not have legal abortion services available. It is impossible to discern what the outcome of an unwanted pregnancy would be in Ireland because there is no access to abortion here. The study is a little strange. It is difficult to apply such studies to Ireland because unwanted pregnancies were examined but there was quite a bit of ambivalence in terms of the unwanted pregnancies as some of the women who had unwanted pregnancies had abortions while others had unwanted pregnancies but did not have abortions. Those were the two groups analysed in the study. In a place where there is no access to abortion, the quality of unwanted pregnancies will be different because one could not say who from a group of women with unwanted pregnancies would have gone on to have an abortion had it been available. It is not possible to do the study in an area that does not have abortion. That is my point. I am sorry if it was a bit obtuse.

Professor Veronica O'Keane

We cannot replicate those findings. There are some studies in countries such as some African states that do not have abortion services or de facto abortion services in a nearby state. The studies are not highly academic because they cannot be. They have to be based on observational or empirical work rather than testing a hypothesis. However, such studies in those countries indicate that suicide occurs because of an absence of the option of abortion. However, we are in the unique situation that we cannot test any such study in Ireland. That is why colleges in the UK such as the Royal College of Psychiatrists, with which we have a very close relationship, tried to answer the question that kept being brought up in Ireland of whether there are adverse mental health outcomes from abortion. Although Ireland was not specifically mentioned, the colleges repeatedly made the point that the question cannot be answered for any country that does not have abortion services. They were very clear about that and it was very helpful of them to do that study because it has informed the debate here. That is why I was somewhat surprised when Deputy Fitzpatrick said abortion has adverse effects on women's mental health. Did Deputy Murphy ask another question?

No, that is fine. It was regarding suicide rates.

Professor Veronica O'Keane

Another member also asked about that and I forgot to answer. Margaret Oates was the tsar of perinatal psychiatry services in the UK in 2002. At that time, suicide was the leading cause of maternal mortality there. As Deputy Murphy rightly said, that was due to post-partum psychosis, which is a very malignant disorder.

It occurs in the few days following the birth of a baby. It occurs in one in 200 live births. The woman becomes very psychotic very quickly. It is considered to be a psychiatric emergency. Unfortunately, some women do not present and they kill themselves. Sometimes they kill their babies as well, very unfortunately. There was a year when maternal mortality from psychosis was the leading cause of maternal death but, to the best of my knowledge, in more recent years it has been cardiac disease that has been the leading cause of maternal death. Psychiatry and suicide is up there among the top three. It is second or third, but not the leading cause, to the best of my knowledge.

I call Deputy Durkan, who has six minutes altogether.

I thank Professor O'Keane for her very interesting submission. I want to ask about studies. In the case of the determination of an unwanted pregnancy or a crisis pregnancy, is there a difference between the two? I ask Professor O'Keane to comment on this. In relation to women who have had to avail of abortion outside the State, what studies have been done on the particular psychological effects of the abortion afterwards? What extent of counselling is available? Is counselling available? I know I have asked this question of other people who have come before the committee. What does the abortion service in the UK normally provide to its own citizens? Does it provide counselling? Does it provide support or advice? To what extent is that advice and support available to Irish women who have to go to the UK for an intervention in pregnancy?

Does Deputy Durkan want to let Professor O'Keane answer answer that much, as there is quite a bit in it.

Professor Veronica O'Keane

A crisis pregnancy is an unplanned pregnancy, as such. A crisis pregnancy can evolve into a wanted pregnancy, where a pregnancy was not timed correctly but it is ultimately wanted, but it can develop into an unwanted pregnancy, where the woman does not want to be pregnant - it was not planned, it was a crisis and it progressed to being unwanted. That would differ from a crisis pregnancy, which is a more ambivalent state. As I said, crisis pregnancies can go on to become wanted pregnancies, and that is not an issue as obviously we do not have a problem. Is that okay?

Professor Veronica O'Keane

The Deputy's second question was about what counselling services were available. Irish women, when they go for abortions, are given what is called counselling beforehand, and really, that is a process of informed consent that is common to all medical procedures that are undertaken. If I start people on medication I would obviously tell them what it is, how it works, what the side-effects would be and what the consequences would be if, for example, they were to get pregnant. An abortion is like any other medical procedure. We have to talk about the consequences of having it and the possible risks involved. Counselling at a more in-depth emotional level is not always, in practice, something that is done. It will be done, obviously, if there is a need for it. Irish women who go across to the UK leave within 24 hours of having had the procedure, and they are usually quite unwell, or at least in a very delicate position and situation, and they are in pain. I guess they do not get counselling before they leave the UK and they do not go back there for counselling.

On the GP care that is provided here, GPs provide counselling care but, unfortunately, there is no proper training for abortion care in Ireland. There is training for the procedures that are used because essentially some forms of surgical abortion are the same as procedures that would be done, for example, for difficult menstruation problems or for retained products of conception, so while there is procedural training, there is not necessarily explicit training in relation to having had an abortion, which is a different emotional issue, obviously, to having the contents of a uterus evacuated. If we are looking to have abortion services in Ireland, and the Deputy made reference to this, counselling would have to be a part of it, but I do not think it is always necessary. I do not think women always need counselling. Some women are quite clear about what they want to do, and it is not necessarily a very complex or a very heartrending difficult problem for them. Obviously, for a lot of women it is very complicated and where counselling is required it should be, obviously, embedded into services and it needs to be. There is no specific counselling for such women when they come home, but GPs are very creative and they are used to dealing with this problem.

The second part of the question is related to residents of the UK and a comparison with the support services. What is the difference there? I will add onto this, if I might, a couple of other questions, which I might be able to get through if I can, and if not the Chairman might let me back in some time in the not too distant future.

I am already allowing the Deputy a little extra time.

I knew the Chairman would and I thank her. Not all European countries have similar unrestricted access to abortion facilities. The UK is one of the least restrictive, in comparison to Germany, where there is fairly extensive counselling before and after. I would like Professor O'Keane's comments on this. My final point, among many, is if a woman has a miscarriage, very often she requires counselling. It is a normal and natural thing and we have all read about it and the lack of counselling on some occasions. How would Professor O'Keane compare the need for counselling following a miscarriage with the need for counselling following an abortion?

Professor Veronica O'Keane

The need for counselling will be determined by the woman who has had the experience. Obviously, as the Deputy said very rightly, miscarriage can be a terrible tragedy for some women, and particularly a late miscarriage is devastating. If a woman is devastated she will need counselling. In a similar vein, we may have a woman who had a very early abortion who is not devastated. All of our medical services and psychiatric services are there to respond to need, so we need to have counselling and psychiatry embedded within our obstetric services, and that is something that is going to happen in the future, but if we are planning to legislate for abortion the Deputy is absolutely correct that we need a model whereby counselling services are available prior to and following procedures. We should not discriminate between whether that is an abortion or a miscarriage. There are counselling procedures in place for women who have late miscarriages or stillbirths. They are established in the three maternity hospitals. We need to expand the range of counselling services for abortion and earlier miscarriages. Again, I would say medical services should be responsive to need, and we need to build it in.

I thank Professor O'Keane for coming in. I know we are pushed for time but I have a couple of quick questions. Professor O'Keane was correct to pinpoint the Citizens' Assembly clearly stating there should not be a distinction between physical and mental health. The irony is, of course, the Protection of Life During Pregnancy Act very much makes that distinction, in that it puts up incredibly onerous provisions in relation to mental health access vis-à-vis physical. I wonder, as a medical professional, in terms of the regulatory or legal environment to allow her to do her job properly, in terms of our job of work, if there is any advice Professor O'Keane could give us as to how she sees us treating this, or the best way forward for her to deal with it.

Professor Veronica O'Keane

That is a really pragmatic question. I cannot represent my profession before the committee today; I am simply an individual. However, there are general principles that apply to this as they apply to all of medicine, and it is worth repeating them.

Risk is unpredictable, especially risk where someone is in a situation of extreme emotional vulnerability. Such a woman is vulnerable because she is pregnant and because she has an unwanted pregnancy. If she is looking for abortion care, she is vulnerable because she is going down a pathway in which she will absolutely need support, although it is an autonomous decision. Such a woman ought to have care provided to her on that journey, including counselling and care for whatever other psychological requirements she may have. We need a framework that is not restrictive - that is the main principle. We need something that will allow clinicians to practise flexible best practices. A clinician cannot practice good medicine with a document like the one in my hand standing over her. A clinician cannot practice good medicine by saying to a woman in every second sentence that she can do something but she should bear in mind that there is a constitutional prohibition. A clinician working in a very circumscribed and highly legalised area where she has to get three, four or five opinions is the polar opposite to what we require. For doctors to practise, we need the prohibition to be removed from the Constitution. We need repeal of the eighth amendment. Then, we need flexible legislation that will reflect the unpredictability and unforeseeable situations that arise in clinical practice.

Pathways cannot be exact. The idea that a woman can walk into any psychiatrist or doctor and then be referred to three specialists within 24 hours and have a legal termination within a few days does not work. It simply does not work like that. We must have a legal framework that will free us and liberate us to practise medicine and psychiatry. At the moment we are working against obstacles. It is an obstacle race that we are trying to negotiate.

I think that is helpful. The need for flexibility has been a theme we have heard from other medical practitioners. This is something that comes up at all of our meetings. It is related to the whole area of criminalisation, which impacts on psychiatrists as professionals. Can Professor O'Keane advise on the mental health impact on women and, potentially, doctors based on her expertise? We know criminalisation does not stop abortion. Is there a quantifiable impact in terms of stigma, isolation, shame and the negative impact these can have? Can Professor O'Keane expand on some of those points? Can we quantify them in any way?

Professor Veronica O'Keane

It is evident in the way that my psychiatrist colleagues have responded to the legislation. Doctors are not immune from discrimination or from feeling the stigma that abortion care brings with it in a country like this, where there is a constitutional ban.

What about the effect on women themselves?

Professor Veronica O'Keane

I understand that, but I have to make the point that the constitutional ban in place creates stigma for people who are practising medicine as well. I believe my colleagues are terrified. They are terrified of the narrow rigid legal framework that they are being told they have to practise within or else what they do will be a criminal offence. We all know the maximum sentence is 14 years. That is the position for doctors. That restricts medical practice. There is the chilling effect that everyone refers to.

The discrimination and stigma facing the women is deeply regrettable and hurtful and it creates unnecessary suffering. Suffering is inherent in life. I work in a profession where people develop psychotic illness in their late teenage years and their lives are changed. The whole trajectory of the family life is changed as well, and that is a tragedy. What we want to do is, as Hippocrates said, prevent unnecessary suffering. Yet, we are creating unnecessary suffering in trying to work within the system that we are working within at the moment. It is creating unnecessary suffering in women.

Women are sitting in airports feeling the shame. I believe we all feel the shame, as I said in my opening statement. I think it is shameful too. One thing will always remain with me. I recall when I walked through an outpatient clinic. RTE Radio was reporting there on the tribunal into the care that Savita Halappanavar had received in University Hospital Galway. I was absolutely shocked and terribly distressed to hear the RTE presenter talking about intimate gynaecological details in a room full of patients. There were so many levels to it. On one level I was the doctor and the patients knew I was the doctor. At that level there was violation of the sacred trust between doctor and patient. It was violation of the most intimate of intimate things that many women would not share with a best friend, mother or sister. Yet it was there being broadcast. We were listening to all of that – I think that is shameful.

We need to move it from a legal constitutional framework into a medical clinic, which is where it belongs. Stigma is a really important mental health issue and is central in the whole problem that this committee is trying to resolve. I wish the committee members all the very best in their work.

We still have next week – we are not finished yet.

Deputy Daly covered some of what I wanted to ask, so I will be quick. Professor O'Keane has said to us clearly that Article 40.3.3o should be taken out of the Constitution. If I understand her correctly, she believes it should be dealt with on the basis of a health issue and health provision rather than the criminal law. I gather that is a correct interpretation. It is helpful for us to hear that from Professor O'Keane.

I would like to go back to a related issue. I am unsure whether the number is correct, but let us suppose there are ten people per day going to Britain and five people taking pills each day. Earlier, Professor O'Keane described the other women-----

Professor Veronica O'Keane

They are left behind.

She described them, understandably, as the women left behind. I was particularly taken by the women who did not have the knowledge or access to information as well as those who did not have the money. There is a money element to the pills as well as for travelling to Britain. Let us consider these women. To what extent would it help if we changed the atmosphere? Professor O'Keane said that we can talk about it now. We certainly could not talk about it clearly in 1983. I was one of those who were around at the time. What can we do to allow those women to come earlier or to be able to access pills earlier rather than have to contemplate a later abortion? How can we deal with that?

As a practising perinatal psychologist, can Professor O'Keane advise on abortion pills? Can she tell women about how to access them? Is she precluded? Does the eighth amendment stop her in that regard? Can Professor O'Keane give us some clarity on that?

Professor Veronica O'Keane

The two questions are linked. They are related to the women who are left behind. For many of my more seriously ill patients with whom we develop long-term relationships, we are like their family. If they need to fill out a form for social welfare, our social worker helps them to fill out the form. If they are trying to get back to work or do courses, our occupational therapist will help them.

The allied mental health professionals work with individuals with serious mental health problems and advise them in different areas of their lives. We cannot advise them in this area. The Deputy is absolutely correct because we are prohibited from helping anyone to procure an abortion. I absolutely cannot tell anybody about how to procure pills. None of us can because it is against the law. We are not allowed to help anyone to procure an abortion and nobody here is allowed to procure an abortion. Yes, it is breaking the law and that has been laid down very clearly in the Protection of Life During Pregnancy Act.

I guess that answers the question as to why in situations where very vulnerable women want abortions, they need the same help they would require if they wanted to look for a disability allowance or to do anything else in their lives; they are very dependent on us. They live independent lives that are as autonomous as they can possibly be within the limitations of their handicaps. Our ideal is to maximise their autonomy, but they need a lot of support. We cannot support them in this area because we are prohibited from doing so. We are prohibited from doing so because there is a constitutional ban on abortion. We are legally prohibited from doing it because it is against the law, with a sentence of up to 14 years applying. That is very regrettable because in situations like this we are not able to practise medicine as we ought to be practising it, namely, by helping and facilitating our patients to live their lives. It is very difficult for them.

The good news is that most of the questions I wanted to ask have been posed and I only have one left. I thank Professor O'Keane for her excellent presentation, which was full of facts and evidence. That is what all of us want to hear. The line that resonates with me most is the one she repeated a moment ago to the effect that the mental health of everybody in Ireland is being damaged by the eighth amendment. I remember campaigning against the amendment in 1983. We need to remember that, at that time, the State was still locking women up when they were pregnant. They were being locked up in the Good Shepherd Convent in Limerick, next door to where I lived when I was a student. Those were the times in which we lived. This amendment is a vestige of that dark culture of hiding everything away, particularly in the context of women. That is the end of the speech.

We heard about rogue agencies, counselling agencies that were not actually offering non-directive counselling but counselling to persuade women one way, namely, to not have terminations. Has Professor O'Keane come across people who have had access to those rogue agencies and, if so, what was the impact on the mental health of those individuals?

Professor Veronica O'Keane

I actually have not had direct contact with somebody. The Senator raises a very important point, namely, that counselling in this area should be completely non-directive. We should support whatever a woman wants to do. The trickiest situations are those in which women do not know what they want to do. They continue through with the pregnancy feeling ambivalent and wondering if they will want the child when it is born. The more ambivalence that is there, the more support women need. We need to direct a considerable amount of our mental health resources to the area of unwanted pregnancies. If women choose to have abortions, that resolves the issue, if the Senator sees what I mean. The situation we are in now, whereby women who choose that they do not want to have a baby and they cannot have a baby, creates a whole set of problems. Non-directive counselling within a framework where we have abortion services available is definitely at the heart of good practice.

I thank Professor O'Keane for her presentation. We meet again; we soldiered through during the debate in advance of the Protection of Life During Pregnancy Bill in 2013.

One could argue that life is never black and white; it is grey and messy. Human relationships are complex and all of that. The Protection of Life During Pregnancy Act exists because of a very blunt instrument in the middle of the Constitution, that is, the eighth amendment. During the debates that resulted in the passage of the Protection of Life During Pregnancy Bill, some outlandish claims were made to the effect that there would be queues of women claiming to be suicidal in order to try to procure abortions. Some of the insinuations in that debate were quite hurtful.

The Protection of Life During Pregnancy Act introduced monitoring systems. In 2015, a total of 14 terminations were carried out under the Act because of a real and substantial risk to the life of the woman due to physical illness. There were nine emergency terminations carried out due to an immediate risk to the life of the woman because of physical illness and there were three because of suicidal intent. Would the professor agree that because only three terminations were carried out in 2015 on foot of suicidal intent, it is clear that many distressed women are still going abroad in very agitated states? From a clinical point of view, where does that leave psychiatrists, psychologists, GPs and clinicians in general in terms of allowing a patient with her files under her arm and in a very distressed state to go an airport and travel abroad to have a termination carried out in another jurisdiction? Where does that leave Professor O'Keane and her colleagues in terms of their ability to care for a patient, either in advance or on her return? Does it put them in a very difficult position in that they cannot counsel or advise patients that a termination may resolve their suicidal intent?

Professor Veronica O'Keane

I thank the Deputy for his questions. He is absolutely right. There have been three annual reports following the introduction of the Protection of Life During Pregnancy Act showing that three women with suicidal intent had the procedure in 2014, three in 2015 and one in 2016. I might have mentioned earlier that my view is that the women who are suicidal and who can travel are going to England. Why would they not? Why would anybody with the means stay here to be subjected to an inquisition before three specialists. Senior specialists are intimidating people. They usually do not live in the same place. They are interrupting their normal routine and such appointments will not usually be during working hours. It is a very difficult process. Why would people subject themselves to that when they can go to the UK? Going to the UK is shameful but a woman subjecting herself to that sort of repeated questioning is soul-destroying and humiliating.

The Deputy is absolutely right; many women are saying, "I'm distressed and potentially suicidal if I don't get this abortion. I'm leaving; I'm out of here." It is the women who cannot travel who become suicidal because they cannot do so. We are actually creating suicidal women and we are creating desperate women by means of this constitutional clamp. I wonder if we would have so many difficulties and so many tragedies regarding abortion if we did not have this clamp. Would situations escalate so quickly? I do not think they would.

That is one point. What was the Deputy's other question?

I will just continue on from that and we will leave it there because time is of the essence.

It is clear from what Professor O'Keane said that the process under the Protection of Life During Pregnancy Act is very cumbersome and is certainly a deterrent to people, particularly as it involves two psychiatrists and an obstetrician, I think-----

Professor Veronica O'Keane

Yes.

-----after referral by another clinician. I refer also to the fact that a woman has to go abroad for a termination. There is obviously a cohort of women in this country who have not the capability or financial means to organise travel. Among both the indigenous population and the migrant community, in particular, there is a strong emphasis on religious culture, and they have views on abortion. Is there a cohort of women who are completely unable to gain access to any form of help or support because the Protection of Life During Pregnancy Act is too cumbersome, because they do not know about it or because England is just too far away?

Professor Veronica O'Keane

Migrant women have all the vulnerabilities. A migrant woman with an unwanted pregnancy represents a case full of all the vulnerabilities. She is not Irish and probably does not have an Irish passport, although she may be at a point where she does. If she is in direct provision, she certainly does not have any financial means whatsoever. I treated women in the United Kingdom who had been raped in wars and who gave birth secretly because their families would have rejected them had they known they were pregnant, even though the pregnancies were forced and, unfortunately, the result of war crimes.

Women live desperate lives sometimes. There are sub-communities, and there are sub-communities in our own culture in which abortion is utterly unacceptable. If the women in question were living in a more compassionate state, their difficulties might not be as extreme. It arises sometimes in psychiatry that families do not believe in psychosis, for example. We are there to help the patient, however, so we can bring in those families and talk to them. We can explain the circumstances to them and give them the education they might never have received. One wins people around and educates them, and things move on. In this situation, however, there is no possibility of helping the woman who is stranded by her culture and by the absence of services. There is no way of pulling her to safety. Therefore, the absence of services within Ireland particularly affects the women in question.

Professor O'Keane made an extraordinary statement in her opening remarks, to my mind in any event, when she said, "I would go further and say that the mental health of everybody in Ireland is being damaged by the eighth amendment". Is this a medical opinion or has the professor carried out research, backing up this conjecture, that has assessed the mental health of every person in Ireland? Does she at least have an inclusive representative group? If not, I presume the professor's opinion is a political rather than a medical one. What about the 80,000 people who marched in this city not so long ago, not far from this building, to retain the eighth amendment?

Does Professor O'Keane wish to respond to that?

Professor Veronica O'Keane

I was asked to come to the Oireachtas as a specialist in mental health. This is a national issue. This is the place where the laws are made and where our legislation is discussed. I am giving an opinion as a mental health specialist and I believed that was the reason I was invited here. On the question as to whether my remark was based on a methodologically driven study, the answer is, "Absolutely not." Much of what I have said here today is based on my own experience and contacts I have had with people who have been in desperate situations. I have made that very clear.

I thank Professor O'Keane for that. Her statement was very sweeping and I was alarmed by it. I thank the professor for clarifying that it is her own opinion. Would she outlaw gendercide where a woman may seek to abort her baby simply because the baby she is carrying is a girl?

Professor Veronica O'Keane

Sorry, that is way outside my remit.

That is probably not a question for a psychiatrist.

It is, perhaps, one for another individual. The professor is a psychiatrist-----

I accept that. I am asking the questions. I am entitled to ask.

Of course. I believe Professor O'Keane has indicated that-----

(Interruptions).

Could we allow Deputy Mattie McGrath to proceed, without interruption?

This is the usual banter we get. This is why the people outside are so annoyed. We cannot ask our questions. I did not interrupt anybody.

As Chair, I am trying to protect the Deputy.

Could we have a small bit of decorum, please?

To follow on from my question, according to an article in The Economist in 2010 this practice has led to a massively skewed sex ratio in China, India, Taiwan, Singapore and elsewhere. The head of the British Pregnancy Advisory Service, BPAS, has said it should be legalised in Britain because women should be free to make the choice. I refer to a baby being aborted simply because she is a girl. Does Professor O'Keane agree with BPAS or would she outlaw sex-selection abortion?

Professor Veronica O'Keane

I have already made it clear to Deputy Mattie McGrath that this is way outside my area of expertise. I feel uncomfortable that this question is even being put to me. I am not going to comment on it.

That is perfectly fine.

The professor may feel uncomfortable but I am entitled to ask the questions. We had a sweeping statement that everybody's mental health is affected by the eighth amendment. I was very uncomfortable with that. Thousands of people in the country are very uncomfortable about it.

Professor O'Keane stated that she is not representing her profession here today and that her views on all the questions are personal.

Professor Veronica O'Keane

Could I ask the Deputy a question?

No, I am here to ask questions. Could I get an answer to my question please? Professor O'Keane can ask me a question any time.

She can answer with-----

But if she does not want to answer the questions-----

She might wish to clarify something.

We were to have Professor Casey here today. She is also a very eminent psychiatrist. Her letter was not read into the record by the Chairman.

Sorry, Deputy-----

I am making this point because I asked during private session to have the letter read into the public record. That should have happened because Professor Casey had elaborated on many views that are the opposite of those of Professor O'Keane.

This actually proves the point that it is a pity that she did not attend.

I am disappointed she did not attend.

If she were here, she would be able to make the points the Deputy would like her to make. There is no facility for me, under the rules of the Houses, to read a letter into the record for a witness who did not appear.

But the Chairman has done-----

Clarification is a different matter.

The Chairman has read other statements into the public record.

Only clarifications.

I had to read my own correction last week; the Chairman refused to read it. We know how biased the committee is. We know the way it is treating the people and we know what is happening.

That is completely unfair.

It is not; it is very true.

I have only read points of clarification into the record up to this point.

I wrote to the Chairman to ask her to read a clarification from my good self and she did not allow it. She said I would have to read it myself.

The Deputy wrote to the CPP, about which I only heard a rumour,-----

-----and I will address that matter.

That is another issue. That is about something else. I read the clarification last week because the Chairman did not do so when I wrote to her requesting that she read it.

It is probably inappropriate to challenge me on this point while there is a witness present and when we are asking questions. The Deputy should, by all means, take this point up with me at another time.

On that point, I offered last week to listen to our three witnesses before I read the clarification. I am not being unfair to anybody. Let us be fair. I am just making the point that we have heard from Professor Patricia Casey, a very eminent psychiatrist, and she asked that her letter be read into the public record here.

On a further point of clarification, the Deputy wrote to me in his capacity as a member of the committee. That is a different from a witness writing to me to make a point of clarification.

Whatever. All I want is fair play and a hearing.

The Deputy is here to make clarifications like the one he has just made now.

I also asked the Chairman to look at a short video-----

And I did.

-----of an animated abortion. That did not happen either.

How are the Deputy's six minutes going?

We are not quite at six minutes.

There are constant, ignorant interruptions from people-----

Excuse me. Could we have order please?

-----who will not tell us where Jean McConville was murdered or her body hidden. Her family-----

Deputy-----

The Senator talks so much about Limerick. There are double standards at this committee. That is the double standard we are dealing with from Sinn Féin,-----

Listen-----

-----which will not tell us where a woman with 12 or 13 children who was abducted-----

The Deputy should respect the Chair.

-----and then the Senator talks about a home in Limerick.

I do not mean me necessarily, but the office I hold.

These facts are unpalatable.

Deputy-----

I am respecting the Chair.

I thank the Deputy. I will move on to the next questioner, Deputy Rabbitte.

Sorry, I was-----

I am speechless.

Excuse me, I want the remark to the effect that I mesmerised somebody to be withdrawn. I am stating what I believe.

The Deputy mesmerised me.

I want that retracted please.

I cannot withdraw from the fact that the Deputy mesmerised me with his contribution.

I want that retracted please.

Sorry, the Deputy-----

I am entitled to come in here to speak. Or am I? Do other members want us to leave this committee completely, like we threatened to? We will have to, if they continue. I want that retracted. I do not believe I mesmerised anybody. I am stating the facts.

Various comments have been thrown across the Chamber.

I did not throw anything at anybody across it.

I am not saying that Deputy Mattie McGrath did. I am only saying that various comments have been thrown around the place and there is no benefit. No good can come from this sort of thing.

Senator Noone has been here a long time now chairing the committee. She should have learned at this stage we cannot have this sideshow and these kind of snide attempts to undermine us.

What sideshow?

I asked the Chairman about Deputy O'Connell's remarks before and she ignored it. I had to go to the Committee on Procedures and Privileges and now this is going on again. Are we having a committee or is it just a charade?

Deputy-----

It is a charade. I want it withdrawn that I mesmerised anybody.

Deputy, I understand your frustration-----

I want that withdrawn. Senator Noone is in the Chair.

-----that the professor did not attend today.

I am not talking about that.

I understand Deputy Mattie McGrath's frustration about that but these are all wider issues.

I am talking about a statement that has been made by Deputy O'Brien that I mesmerised members of the committee.

I said Deputy Mattie McGrath mesmerised me.

I cannot control how members-----

The Chairman does not want to control-----

-----because she is totally biased. I am leaving this charade right now, for today anyway. I am exposing what it is. It has been a total absolute charade, from the start. The Chairman sat at a meeting in England last week again, trying to get people over here to talk about bringing abortion into Ireland in the middle of this committee.

The Chairman needs to do something about Deputy Mattie McGrath standing up and pointing his finger at the Chair. Deputy Mattie McGrath is so disrespectful. The Deputy is standing and shouting across at the Chairman.

I am making my point that it is a charade and Senator Ruane is part of the charade.

We can see the charade.

It is not on. Everybody is here trying to do their work and trying to engage with the witness, and it is absolutely unbelievable.

If it is Deputy Mattie McGrath's choice to leave, I would be grateful if he did.

I will leave but I want that record corrected.

"Mesmerised" is not an offensive word. The definition is, "capture the complete attention of someone, transfix".

Sorry, can we have some order in the room?

If Deputy Mattie McGrath chooses to accuse the Chair of being biased, I do not believe in silence as consensus. I do not subscribe to the Chair being biased. I do not see any bias.

I call Deputy Rabbitte.

I thank Professor O'Keane. I am sorry I missed some of the professor's presentation but I have read it. I will not apologise for anybody who has spoken in the last few moments but it was not proper or appropriate that one of our guests would be spoken to in such a manner or had to witness it, but I will continue.

The questions I had prepared for Professor O'Keane are as follows. We have heard in previous sessions about the difficulty of quantifying risk and serious risk in respect of physical health. Is it possible to quantify risk or serious risk in relation to mental health? That is one of my questions. Will I ask the two questions together?

Professor O'Keane outlined the negative impact that maternal mental health issues can have on a child's development in the womb and after birth. Are these issues of maternal mental health being properly addressed in Ireland at present and if not, how can we do better?

Professor Veronica O'Keane

The first issue of risk - Deputy Rabbitte has put her finger on the button there - is very difficult to evaluate. It is unpredictable because risk can change very quickly. I have outlined - I do not want to repeat too much - that women who are pregnant are vulnerable emotionally, because of what is happening to them but also because physiologically the gestational hormones alter the emotional centres in one's brain. Anxiety symptoms and depressive symptoms are much more common, even from women who do not suffer from depression, when women are pregnant. There is this vulnerable background. In such situations, what might not be something tremendously challenging can become something tremendously challenging. Amplification can occur in terms of emotional responses. Psychiatric presentations can be unpredictable and unforeseeable and that is because of the nature of the pregnant female brain. We need to allow for that. That is why I really liked the recommendations of the Citizens' Assembly. Although almost 100% - it was 95% - recommended that abortion be available for women who are at risk of suicide, almost 80% stated that abortion should be available for women whose health was at risk so that the range between the highest risk and the lowest risk was only 20%. That is a narrow range. That reflects the unforeseeable fluctuations that can occur. Risk cannot be gauged rigidly. It cannot be fixed. That is important for the legislators to understand in terms of mental health problems that might arise.

The second issue Deputy Rabbitte asked about was maternal mental health. I guess it is broader than maternal mental health services. It is women's mental health because if women choose to have abortions then it is not really maternal mental health. We need to see women's mental health. The National Women's Council of Ireland has been lobbying for this for quite a long time. Its phrase is gender-sensitive mental health services or health services. That is a very good way of looking at it because there are some issues that are very sensitive to one's gender. Of course, reproductive health care is one of those areas. The services are bad at present but clinicians and the leaders within the health care systems are all working hard to improve services and to improve the delivery of services. I suppose the national maternity strategy has had a sluggish start with a little bit of remonstrating, but the mental health services are very much an intrinsic part of the services that will be developed now.

In psychiatry as well, there is the area of perinatal psychiatry. I do not want to go into Dr. Anthony McCarthy's territory. He will be talking about that and I do not want to duplicate any information that the committee might be given. Dr. McCarthy will address that for the committee in a fuller sense. Is that okay?

I thank Professor O'Keane.

I thank Professor O'Keane for attending here today. We really appreciate her time and the care that she gave in answering all of the questions that the members have asked. We might just take a five-minute break.

Professor Veronica O'Keane

I would just like to say that I have been very impressed by the Chair's skills.

I thank Professor O'Keane.

Sitting suspended at 4.27 p.m. and resumed at 4.36 p.m.