Professor Patricia Casey:

I thank the Chairman and members of the committee for inviting me to address this meeting on the expert group report on the A, B and C v. Ireland case. The committee secretariat should have my biographical details and if the Chairman wishes, I can provide him with my current CV. I have also all the scientific papers that I cited in my longer submission should he need them.

I wish to make two major points. First, suicide in pregnancy is very rare and when it occurs it is associated with mental illness. Mental illness in pregnant women can be treated and should be treated in the same way as it is in any other person in the population. The second point I want to make is that there is no evidence that abortion reduces suicide risk in pregnant women, and there is some evidence that it may have a negative effect in some instances.

Suicide in pregnancy is rare but it does occur. Dr. McCarthy has made most of these points already. A common theme running through much of the research in this area is that suicide during pregnancy is lower than at any other time in a woman's life. There is some protection for women during pregnancy apart from a small group who have major mental illness and who are at risk during pregnancy. It is important that we understand the rarity of suicide in pregnancy because there is an impression out there that many women in Ireland are dying by suicide because we do not have appropriate legislation to govern it. That is not the case.

Let us look at the figures to put the matter into context. The national suicide rate in women has been static for decades. The rate has been unchanged for four to five decades. In 2011, 100 women died by suicide. How does that compare with the figure for the number of women who die in pregnancy? A review of the three maternity hospitals in Dublin over a 21 year period found that there were no deaths during pregnancy that involved the delivery of more than 680,000 live births There were no deaths during pregnancy during that 21 year period. Turning to the British figures, the Centre for Maternal and Child Enquiries, CMACE, is the British organisation for examining mortality. We have recently aligned ourselves and become involved with that. Again, the British figures, to which Dr. McCarthy alluded, identified four deaths by suicide in a three year period. That is roughly one per 500,000 maternities. Of those, all had major mental illness. The report found that 69% had sub-optimal care. They were not diagnosed as having mental illness, they were given the incorrect treatment or treatment was stopped. There were problems of that sort with them. The Irish equivalent of that body has identified two deaths by suicide in Ireland in its draft report. It probably will not be published for a few years. We do not have any further information other than there were two suicides.

This information confirms that suicide in pregnancy is rare and that it is related to significant mental illness. The authors of this study also emphasise the critical importance of identifying and treating mental illness in pregnancy adequately. The report also sadly found that four women died during pregnancy in Britain. That is in a country in which abortion is readily available. These deaths had nothing to do with the non-availability of abortion but rather to do with the inadequate treatment of mental illness.

An issue related to abortion and suicide is our ability to predict suicide. We are not good at predicting suicide. That is not because we are incompetent but because it is inherent in suicide that it is very difficult to predict. It consists of behaviour that is often unpredictable and somebody might be suicidal one day and a few days later be perfectly well. Other things might happen in their lives to remove the suicide risk or introduce new suicide risk. We are not good at predicting suicide. There are numerous studies suggesting and showing that, in fact, we are wrong more often we are right. In a hundred cases of people who would be predicted as dying by suicide, only three will actually die by suicide, according to some of the studies.

A woman who is pregnant and suicidal, as Dr. McCarthy states, needs proper treatment. In my clinical practice, as I am sure every other psychiatrist in the country does, if somebody is suicidal and at immediate risk, we admit them to hospital. We carry out a full assessment of them as well as getting background information from family members and their GPs. We arrive at a diagnosis and a plan of treatment. That can take time.

In my work as a psychiatrist, I run the attempted suicide service in the Mater Hospital in which we see and assess more than 400 attempted suicides in women per year. I have never seen a pregnant woman who was suicidal for whom an abortion was the only answer. I have seen pregnant suicidal women who needed admission to hospital, who were very ill and who needed treatment. I have seen pregnant suicidal women who have taken overdoses and asked for an abortion, but having spent time with them and conducted a full assessment and talked to them, in the two instances I am referring to, both women were being coerced by family and partners. The reason for the overdose was not because they wanted an abortion, even though on the surface that is what they said, but because they wanted to escape the incessant pressure that was being placed on them to make a decision to have an abortion. With support, they ultimately decided against the abortion and, I understand, gave birth.

That brings us to the next question. Is abortion an actual proven treatment for women who are suicidal? There is no evidence that abortion is a treatment that helps women's mental health or prevents suicide in pregnant women. This was recently investigated by a very large-scale study carried out by the medical royal colleges, headed by the Royal College of Psychiatrists in London. This examined all of the quality studies that were published in peer reviewed papers to ascertain whether abortion harmed women's health or helped their mental health during pregnancy. The outcome was the same: whether women with unwanted pregnancies gave birth or had abortions, it made no difference to their mental health. They identified one crucial element in a sub-group of people for whom abortion caused mental health problems.

They were people who had prior mental health problems. Those whom one would think might benefit from an abortion were actually those most at risk of problems.

To summarise, suicide in pregnancy is rare. On the basis of the studies that have been done, there is no evidence that abortion helps women's mental health. Twenty years have passed since the X case decision. We now have much more information about the impact of abortion on women's mental health, including the possible harms associated with it. In essence, X case legislation would expect doctors to recommend an intervention - an abortion - that has not been shown to be of benefit to mental health in order to prevent a rare outcome - suicide - that cannot be predicted. In my view, legislation for the X case that includes suicide risk is not supported by any scientific evidence. The two tests envisaged in the X case - that suicide will occur, on the balance of probability, and can only be averted by abortion - cannot be met. In my opinion, suicide risk as a ground for abortion should be excluded from the X case legislation.