Some years ago, facing a series of tearful and terrified teenage girls who wanted to travel to the UK to have an abortion, I was struck by the cold-heartedness of putting traumatised teenagers through the hoops of questionable legal procedures to access medical services they had clearly given informed consent for. These were ‘unaccompanied minors’ in the care of the HSE whose carers were looking for approval to facilitate access to abortion services by accompanying these pregnant children to the UK. The certification I issued advised that where informed consent had been satisfactorily given then restricting access to abortion would increase the risk of suicide and this was accepted by the High Court unquestioned. However, forcing these vulnerable children through such a process of fear, uncertainty and delay left me with an abiding sense that we were not much further on from the days of the Magdalene laundries.
It had taken the tragic case of Ms X, a 14-year-old child who had been raped by a neighbour, to bring Ireland to its senses. The idea of continuing to refuse an abortion to a child, who had become suicidal after she was refused permission to travel for an abortion, was more than we could bear and thousands marched to demand her right to access an abortion. A constitutional amendment in 1992 meant the threat of criminal sanction was removed from the roughly 5,000 Irish women who travel abroad for abortions every year, a normal health service in every European country bar Malta and Vatican City. Despite this step forward, the costs of travel and accommodation means for many women a delayed and lonely process that complicates their medical care and reinforces the sense of stigma attached to women’s reproductive health in Ireland.
In its 2009 report on Maternal Mental Health, the UN’s World Health Organisation (WHO) has highlighted the increased risk of mental health problems in, “unintended pregnancy especially among adolescent women”. The WHO emphasises the further risk from factors such as poverty and lack of support, “including lack of reproductive rights” which means access to abortion services but also access to good quality obstetric, gynaecological and contraceptive services as well as sex education and information. Denying women ‘the right to choose’ raises the risk of suicide in pregnancy. Professor Robert Kendell summarised this conclusion in the title of his 1991 review in the British Medical Journal: ‘Suicide in pregnancy…much rarer now: thanks to contraception, legal abortion and less punitive attitudes’. The availability of abortion services in the UK and elsewhere in Europe has saved countless women from the horrors of backstreet abortions and suicidal despair.
Despite this evidence from history, and from other countries even today with severely restrictive abortion laws and high rates of death from unsafe abortion and suicide, the opposing notion that choosing an abortion increases the risk of mental health problems, and even suicide, persists. When this allegation is systematically investigated by emphasising good quality research it is found to be false. In the US, the American Psychological Association in 2008 found there was no credible evidence that freely choosing to have an abortion raised the risk of mental health problems. In the UK, the National Collaborating Centre for Mental Health’s review in 2011 reached the same conclusion. While a higher rate of mental health problems may be found in women who have had an abortion, when factors such as unwanted pregnancy and previous mental health problems or experience of violence is taken into account there is no higher rate overall. This means previous mental health and unwanted pregnancy are the likely risk factors; not the choice of abortion. It is also well known that, following abortion, mental health problems are more common where a woman has had a negative attitude to abortion before or a negative reaction after, especially when she has been under pressure to have an abortion. Clearly, the ‘right to choose’ must be without pressure to choose a certain way. Women who have repeated abortions are also a group who need particular attention aimed at preventing further unwanted pregnancies. Good counselling and practical social support, before and after the decision to have an abortion or not, is the key to supporting women with unwanted pregnancies. Being prochoice means supporting a woman’s right to choose to have a child by advocating for the back-up of good obstetric and childcare services after the child is born.
Anti-choice proponents have repeated the slogan that ‘Abortion is not a treatment for suicidality’. No doctor has actually argued that it is. However, in response to this crude formulation, it could be argued that abortion, for those who choose it with proper supports, can be as much a ‘treatment’ for the risk of suicide as blood pressure tablets are a ‘treatment’ for the risk of a heart attack. Both can be preventive, lowering the impact of a relevant risk factor: that is, the distress of an unwanted pregnancy and high blood pressure respectively. The ‘treatment’ for unwanted pregnancy is ‘non-directive counselling’ and the ‘treatment’ for suicidal risk in unwanted pregnancy is ‘risk-reduction’, which includes facilitating the choice of accessing abortion services.
In the Irish context, the restriction of access to abortion services is mediated by restrictions on travel. This means a greater risk of suicide in women too sick to travel, but also adolescents, women with young children, migrant women, women with disabilities, women with no or low incomes and practical difficulties travelling may also affect women whose pregnancy involves a fatal foetal malformation or was the result of rape or child sexual abuse.
The obvious solution to all these risks is to end the unnecessary, dangerous, and, for the most part, ineffective legal restrictions on abortion services in Ireland. This is the very successful approach taken in Canada for the last 25 years. Abortion there is subject to healthcare guidelines and not criminal law; just like every other medical service. Abortion as an option in unwanted pregnancy is a decision between the patient and her doctor. Support services should try to ensure that the woman has the best informed choice but do not attempt to influence that choice or take it for her. Coercion has no place in this decision. Restricting access to abortion increases suicide risk and supported choice reduces that suicide risk. While ultimately there is no medical need for a special legal framework for abortion, doctors are perfectly capable of certifying the need to support a woman’s choice of abortion services to reduce her risk of suicide. It does not take a panel of doctors to do this. It is time to move on from the Magdalene era where religious and political prejudice was allowed overrule the personal freedom to choose.
Article written by Dr Peadar O’Grady (Consultant Child and Adolescent Psychiatrist and member of Doctors for Choice) for the Sunday Business Post, Ireland, April 28th 2013