BY ARIELA ZEBEDE

Ireland has some of the strictest abortion laws in the world, only allowing abortion in order to save the life of the mother. The laws are unclear in some situations, however, sometimes leaving pregnant women trapped in situations that may damage their mental or physical health. Moreover, victims of rape and incest are denied the possibility of an abortion. As a result, many travel outside the country to abort unwanted pregnancies, but this option is unavailable to the poor and undocumented. Ireland, despite these distressing facts, has a stellar reputation for gender equality.1,2 Seemingly positive statistics hide the dire, inequitable climate for women that the country’s strict abortion laws have created.

Ireland’s abortion laws gained public attention in 2012 when Savita Halapannavar died from pregnancy complications. Even after Halapannavar began to suffer from serious infections and her doctors declared that a miscarriage would be inevitable, her doctors told her that under Irish law, “if there’s no evidence of risk to the life of the mother, our hands are tied so long as there’s a fetal heart[beat].” Her illness progressed until the fetus’s heartbeat stopped, but by that point, she was beyond saving.3 The political uproar surrounding Savita’s preventable death lead to the 2013 Protection of Life During Pregnancy Act (PLDPA). The new legislation specified the circumstances under which doctors could legally perform an abortion. These circumstances include: (1) the “real and substantial” risk of loss of life from physical illness; (2) the “real and substantial” risk of loss of life from physical illness in an emergency, or (3) the “real and substantial risk” of loss of life from suicide. Critics of the new law, however, have argued that it “fails to properly protect women’s lives and further criminalizes women who access abortion service.”3

This failure comes, in part, from the legislation’s lack of clarity about what is considered a “real and substantial risk.” At what point does an illness shift from a threat to health to a threat to life? Few medical choices are black and white, and doctors cannot be absolutely certain that a person will die until it is likely too late to save them. Moreover, current law threatens doctors with up to 14 years in prison for an unlawful abortion, which may cause medical personnel to err on the side of protecting the fetus, allowing the mother’s condition to worsen and decreasing the likelihood of successful treatment later on.3 A law that allows for abortion only when there is a risk of death disregards longer-term risks associated with allowing an illness to go untreated. These future health issues can become more expensive for the state down the line and, more importantly, the untreated patient may experience lifelong health complications and a significant decrease in quality of life. The suicide provision seems like it could be interpreted broadly, but the law actually outlines extremely specific rules under which it applies. The Irish Department of Health’s “Guidance Document for Health Professionals” elaborates on the PLDPA. In order for someone to qualify for an abortion, they must demonstrate “suicidal intent.” This language implies that doctors may only deem a woman qualified if she is actively suicidal, or suicide is imminent.3 The line between “imminent” and too late, however, is extremely fuzzy.

Logistically, approval for an abortion must be granted by three different doctors: an obstetrician and two psychologists. All three doctors must have very specific qualifications. These measures are meant to prevent a mentally stable person from using the suicide exception to abort an unwanted pregnancy, but the need for such an exhaustive process suggests a general skepticism about women’s mental health. Furthermore, this process is particularly burdensome for a woman who is already in a difficult mental state. The effort to prove one’s suicidal tendencies to three skeptical doctors, all while carrying an unwanted child, will exacerbate a preexisting mental illness.

In all three life-threatening scenarios, doctors must certify that the only way to protect the life of the patient is by terminating the pregnancy.4 Even if an abortion would alleviate her condition, abortion is still avoided at all costs. With so many types of alternative medical treatments available, only an extremely specific scenario would require an abortion to evade all risk. An illness that merely worsens because of pregnancy would not qualify. Specifically, in the case of suicide, determining that only an abortion will mediate the risk of death is nearly impossible. Suicidal intent and ideation result from a combination of factors that may only worsen when a mother-to-be is forced to carry an unwanted pregnancy.

Ireland’s abortion laws even exclude provisions included as exceptions to the “stricter” abortion laws of many other nations. For example, in cases of fetal impairment so severe that the child will die almost immediately after birth, a pregnant woman must carry that fetus for the full course of nine months, and give birth to the child with the knowledge that that he or she will soon die. In addition to the typical physical tolls of pregnancy, such as nausea, bladder control issues, and the process of childbirth, this situation will cause expectant mothers significant emotional strain. One woman who traveled abroad for an abortion recounts, “How cruel would it be to …. put me through a full pregnancy, I would have the breast milk, I would have everybody asking me how long are you gone?… How could they think that would not affect someone mentally? I could never have gone through that, I just couldn’t.”3 A growing baby bump serves as a constant reminder of the tragedy that a mother will ultimately face. Even looking at the live baby while knowing that he will soon die can be devastating.

In cases of rape, a reality for approximately 7.5% of Irish women, abortion is still criminalized.5 Incest, too, bears no abortion exception.3 Ireland’s current laws provide no support for victims of rape or incest. On the contrary, the government ultimately forces them to choose between committing a crime and bearing the children of their predators. A woman who has already experienced a great deal of trauma, both psychologically and physically, must instead face the obstacles that stand between her and an abortion. The United Nations’ Committee Against Torture points out that, when abortion in cases of rape, incest, or an unviable fetus is illegal, victims are “constantly reminded of the violation committed against them, which causes serious traumatic stress and carries a risk of long-lasting psychological problems.”6 If a woman tries, for example, to obtain an abortion through the suicide exception, she will be forced to relive her traumatic experience three times, with three different doctors. She will likely fail in her efforts to qualify for an abortion; the growing fetus, then child, will constantly remind her of her trauma.

Because legal abortions are essentially unavailable in Ireland, women who want them must look for other options. Some pursue illegal abortions, primarily induced by medication (typically mifepristone and misoprostol). Those who buy these medications spend approximately €177 (roughly $200) on average, a doable price for most. But taking medication illegally and without medical supervision puts pregnant women at risk for untreated complications; in addition, these pills earn women up to 14 years in prison under the PLDPA. Still, many women continue to pursue that option for its affordability. In 2014, Irish customs and the Health Products Regulatory Authority (HPRA) seized 1,017 tablets of mifepristone and misoprostol from the mail.3 Ireland’s restrictive abortion laws put pregnant women at risk for both medical complications and significant jail time.

Furthermore, approximately 300 women and girls travel from Ireland to Britain every month in order to terminate their pregnancies.7 This number, however, is an underestimate as it does not include those who travel to countries other than Britain, or those who do not provide their Irish addresses for confidentiality reasons. Although travel is a legal option used by many, it is not problem-free. First, Irish healthcare practitioners do not offer women much information about this option. The Regulation of Information Act restricts information about abortion abroad, and bans any information that advocates or promotes abortion. This act prevents doctors from giving their patients all of the necessary information, compromising the doctor-patient relationship. Moreover, the journey is both costly and complicated. Amnesty USA describes how

Women and girls in Ireland must first identify a reputable clinic or hospital and then try to book an appointment on a date that they are able to travel, and that meets their medical and financial restrictions. Once an appointment is made, the woman may then need to arrange for her medical records to be sent to the clinic or hospital abroad. Employed women, and their travel partners, must arrange to take time off work – clinics typically operate only on weekdays. Women with children need to arrange childcare. In order to enter the [United Kingdom] or another [European Union] country they must have identification that shows their nationality, ideally a passport. Flights or ferries must be booked and, for some, accommodation reservations made.3

After all of these preparations, women must then pay for the actual procedure. In total average cost for the entire trip ranges from €1,000 to €1,500 ($1,225 to $1,695).3

Women who travel to get abortions are also unable to receive follow up care upon their return, making it difficult to receive treatment if complications arise or an abortion is incomplete. Others who make the trip, discover upon arrival that they cannot undergo an abortion for various medical reasons. A woman who has delayed her travel in order to obtain necessary funds, for example, may no longer be able to undergo a safe abortion.3 While just over one fifth of English women aborted their pregnancies at ten weeks or later, one third of Irish women receive such late-term abortions.8

The PLDPA states that the act does not limit the freedom to travel in order to receive an abortion.9 Although many Irish women take advantage of that option, travel isolates groups of women who either cannot afford to make the journey, or are unable to do so for other reasons. 8.3% of women in Ireland live in consistent poverty; they can neither pay for travel expenses, nor afford to take time off of work.10 Asylum-seekers receive a weekly allowance of €19.10 or $22, a small compensation that leaves them poor and trapped in Ireland until their refugee or immigration status is determined, a process that can take years to resolve. Migrant women, too, may need special papers to travel. These women may seek abortions not only for personal reasons, but also because they may not have the means to support a child.

In a state of desperation, women are more likely to pursue illegal, dangerous options. The United Nations Human Rights Committee expressed concern for poverty-stricken women, but Irish representatives retorted that they had “no solution” for women who are unable to travel.11 The government seems to justify its restrictive abortion laws by protecting the “freedom” to seek abortions elsewhere. This freedom, however, is limited to those who can afford to travel and have the requisite documents on hand. The government’s inaction on behalf of those who do not have the means to leave Ireland effectively prevents certain groups from receiving an abortion. This inequality can be psychologically and physically devastating, and reinforces preexisting inequalities within Ireland.

Ireland’s Eighth Amendment considers the right to life of the unborn equal to that of the mother. This amendment has implications that extend beyond abortion laws. The Association for Improvements in the Maternity Services Ireland writes:

[T]he Eighth Amendment is repeatedly used in the context of maternity rights to deny the right to bodily autonomy in terms of decision making in pregnancy, in labour, in birth and in the postpartum period. Women have reported being forced into caesarean births, forced into invasive procedures during labour, threatened with social services, and in some cases threatened with the Gardaí [police] and mental health services for trying to assert their right to bodily autonomy.3

In December 2014, a clinically dead pregnant woman was kept on life support despite her family’s insistence that she be allowed to die, violating principles of informed consent that typically regulate doctor-patient relationships. Another woman who shared her story stated simply, “It was always what was best for the baby, not what was best for both of us equally.”3

Research on maternal health has shown that an emphasis on maternal health maintenance positively impacts the health of future generations.12 The mental health impact upon mothers who cannot acquire abortions cannot be understated. Because of the active pro-life movement in Ireland, the stigma surrounding abortion is so strong that many who seek abortions abroad travel in secret to prevent discovery by their neighbors. The trauma experienced by victims of rape and incest only grows when very little can be, or is, done to alleviate the trauma. For those who decide to seek abortions, travelling or pursuing illegal alternatives cause significant stress, as well. Irish doctors have confirmed that the financial pressures, as well as the isolation from health services and family, that women experience when they are forced to travel abroad for safe abortion services negatively affects their health.8 These mental stresses upon the mother can have negative impacts on the child as well, as studies have suggested that women who experience high levels of stress during pregnancy are more likely to deliver premature babies.12

All in all, Ireland represents an atypical case. Typically, strict anti-abortion laws are associated with countries that are either underdeveloped or generally unsupportive of women’s rights and health. Meanwhile, Ireland’s GDP per capita is comparable to that of the United States, the World Economic Forum ranks Ireland fifth (behind four Scandinavian countries) in gender equality, and Ireland boasts a low maternal mortality rate compared to that of the rest of the world.13,2

But statistics can be misleading, and here, they mask real harm and inequality. The gender equality statistics mostly take into account economic, political, and educational issues, allotting little weight to female life expectancy and sex ratio at birth. No statistic on female body autonomy or women’s treatment even exists in the health system. Even so, Ireland’s “sub-score” for life expectancy is ranked at 56 world-wide. Moreover, Ireland’s maternal mortality rate is actually average for developed countries.14 The country’s economic status implies that more people can afford to travel abroad in order to obtain an abortion. It is possible that traveling prevents many would-be maternal deaths. Also, it is possible that records list pregnancy as only an indirect cause of death, one of a number of contributing factors. Extended pregnancy, for example, may cause later health complications that ultimately lead to death. These health complications, rather than the pregnancy, would be listed as the “cause of death.” Furthermore, similar to laws that establish a clear distinction between “health” and “death,” cause of death statistics ignore the importance of quality of life. Pro-life advocates in Ireland use Ireland’s maternal mortality rate as justification for its abortion laws.15 Health systems should, however, strive to protect not only the lives, but also the health of all patients. The Irish system does not accomplish such a goal. Instead, Ireland limits the options of pregnant women, creating a toxic environment for women’s health.

Ariela Zebede is a sophomore in Pierson College from Miami Beach, Florida. She can be contacted at ariela.zebede@yale.edu.

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References:

Taylor, C. (2015). Ireland Ranked as One of the Best in Terms of Reputation. The Irish Times. Retrieved from: http://www.irishtimes.com/business/economy/ireland-ranked-as-one-of-the-best-in-terms-of-reputation-1.2287594. Schwab, K., Samans, R., Zahidi, S., Bekhouche, Y., Ugarte, P. P., Ratcheva, V….& Tyson, L. D. (2015). The Global Gender Gap Report 2015. World Economic Forum. Retrieved from http://www3.weforum.org/docs/GGGR2015/cover.pdf. She is not a Criminal—The Impact of Ireland’s Abortion Law. (2015). Amnesty International. Retrieved from http://www.amnestyusa.org/pdfs/Ireland_She_Is_Not_A_Criminal.pdf. Implementation of the Protection of Life during Pregnancy Act 2013 (2014). Ann Roinn Slainte Department of Health. Retrieved from http://cdn.thejournal.ie/media/2014/08/doctor-guidance1.pdf. Facts and Information about Sexual Violence and Rape. (2016). Dublin Rape Crisis Center. Retrieved from http://www.drcc.ie/get-help-and-information/facts-and-info-about-sexual-violence-and-rape/. Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment [PDF]. (2011). United Nations. Retrieved from http://www2.ohchr.org/english/bodies/cat/docs/CAT.C.PRY.CO.4-6_en.pdf. Abortion Statistics, England and Wales: 2014. (2015). UK Department of Health. Retrieved from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/433437/2014_Commentary__5_.pdf. Abandoned and Stigmatized: The Impact of the Irish Abortion Law on Women. (2014). Center for Reproductive Rights. Retrieved from http://tbinternet.ohchr.org/Treaties/CCPR/Shared%20Documents/IRL/INT_CCPR_CSS_IRL_17442_E.pdf. Protection of Life during Pregnancy Act 2013. (2013). Retrieved from http://www.irishstatutebook.ie/eli/2013/act/35/enacted/en/pdf. Consistent poverty rates. (n.d.). European Anti-Poverty Network Ireland. Retrieved from http://www.eapn.ie/eapn/training/consistent-poverty-rates. Ireland at the UN: We Have ‘No Solution’ for Women Who Can’t Afford to Travel for an Abortion. (2014). Thejournal.ie. Retrieved from http://www.thejournal.ie/ireland-unhrc-day-twp-1572161-Jul2014/. Healthy Mothers, Healthy Babies: South Carolina’s Plan to Reduce Infant Mortality and Premature Births. (2013). DHEC. Retrieved from https://www.scdhec.gov/library/cr-010842.pdf. The World Factbook. (n.d.). CIA. Retrieved from https://www.cia.gov/library/publications/the-world-factbook/rankorder/2004rank.html Myth #6: Ireland, Without Abortion, is the Safest Place in the World for Pregnant Women. (2014). Abortion Rights Campaign. Retrieved from http://www.abortionrightscampaign.ie/2014/03/06/myth-6-ireland-without-abortion-has-the-lowest-maternal-mortality-rate-in-the-world/. Maternal Mortality Rates. (2016). Profile Campaign. Retrieved from http://prolifecampaign.ie/main/maternal-mortality-statistics/.