Dr. Anthony McCarthy:

I thank the committee for inviting me to address the committee. I hope to be able to answer any questions which members might like to ask by bringing the benefit of my experience and expertise, and my knowledge of the research in the field of pregnancy and mental health and illness. I have worked as a consultant perinatal psychiatrist at the National Maternity Hospital in Holles Street for the past 21 years where more than 500 women attend the clinic each year. Women are seen who are pregnant or who are in the first six months post pregnancy, which includes pregnancy loss, and where a significant mental health issue is involved. Women attending may have a previous mental health history or a significant new crisis may develop during or after the pregnancy. Among those who attend will be many who have suffered a miscarriage. Others may have had a stillbirth or may have a baby diagnosed with a significant abnormality of varying levels of severity, may have had a previous termination or may be considering a termination.

I have previously spoken as an expert witness at the two Oireachtas hearings which led to the introduction of the Protection of Life During Pregnancy Act 2013. I was also invited to speak as an expert witness to the Citizens' Assembly. I am also an expert assessor for the Confidential Enquiry into Maternal Deaths in the UK and Ireland. This involves detailed study of the records of women who have died during pregnancy or in the first year afterwards, as a result of suicide or other mental health causes.

What I can say now after all of these years of working in this area, and from my understanding of relevant research and of history, is that while having a baby is, hopefully, and fortunately for many, one of the most joyful, rewarding and meaningful experiences of their lives, as the committee members all will be aware, it is also unfortunately so often not like this. The committee members will know this from their own lives, those of their families and friends, and of course, also from listening to many of the stories told here to this committee and to the Citizens' Assembly. Most of the committee members will have heard of, or personally witnessed, stories of depression or distress, of unwanted pregnancies, of rape, or the discovery of major foetal abnormalities, or of the termination of pregnancies in the UK and here in Ireland. These are stories heard so regularly in my clinic in Holles Street.

In an ideal world, abortion would never be needed or requested, but even if we exclude medical emergencies and severe life threatening indications, we cannot wish abortion away. It has been a part of the history of every country, including Ireland, and before it became legally available in the UK 50 years ago, and therefore available for thousands of Irish women every year since, it was illegally available here in Ireland for those who could pay. Of course, there was infanticide, too, which was such a widespread practice. I would urge anyone who is unaware of the nature and extent of this to read Dr. Clíona Rattigan's seminal history, What Else Could I Do?, a detailed study of hundreds of cases of infanticide in Ireland between 1900 and 1950, or the work of Dr. Elaine Farrell, who studied 4,645 infanticides in Ireland between 1850 and 1900 and published her work, entitled A Most Diabolical Deed. Dr. Rattigan quoted a judge in County Clare in the 1930s who described the "epidemic of infanticide cases" he had to hear. Both studies emphasise that these numbers were an underestimate of the true scale of infanticide in Ireland at that time. We do not want to go back to an era of illegal back street abortions and infanticide.

In my clinical work, of course, most of the women who I see for whom a termination of pregnancy is an issue are seeing me because of their or their partner's concern about their mental health. Sometimes that termination could potentially be very damaging for them. For example, a woman who has a planned and much wanted pregnancy, but who develops severe depression which is clearly clouding her judgment about everything in her life, and not just the pregnancy, keeps thinking she should terminate because she would be a bad or evil mother. She needs expert help for her depression. A termination is almost certainly not what she wants and could be very damaging to her mental health long term. For another, however, she is clear that she cannot continue the pregnancy, she cannot cope and continuing the pregnancy would destroy her life.

She is in no way mentally unwell but she may be terrified of becoming unwell.

How any woman responds to a pregnancy is personal to her and how she visualises and imagines what is or is not growing inside her is unique. For example, one woman who has an early miscarriage will say that what she lost was a just pregnancy for her, not a baby, that she knows it happens in 20% of all pregnancies, and it is just nature’s way. It was just like a heavy period. For another, she may have a huge sense of loss of a baby, name it and grieve for it, even if the scan actually showed a so-called empty sac, or even if she has had a rare molar pregnancy where there was only ever placental tissue and no foetus but her pregnancy tests were repeatedly positive and she may grieve as though it was a baby.

These sorts of inner perceptions and beliefs and imaginings that determine so much, and often more so than any biological reality. It is part of what makes us human. One woman with a baby with a fatal foetal abnormality may decide that she or they want to continue the pregnancy because she wants to hold on to that baby inside her as long as possible, and she hopes that the baby will die inside her and not shortly after, as it is safe and warm inside of her. Another will feel she cannot bear to think of the baby suffocating inside her or being in pain, or the distress of it dying inside her. She loves that baby but she will want a termination and she will love it afterwards. Another woman will say she wants the baby delivered early and hopefully alive still so that she or they will be able to hold the baby for a few minutes before it dies, and may bring the pregnancy on early for that reason. As doctors we must be aware of the complexities involved for everyone, and listen and not prejudge.

I now turn to mental health outcomes after induced abortion and the research evidence in this area. It has been mentioned by members of the committee and some speakers in earlier sessions. It is important to note that no significant research on this subject has been completed in Ireland. Research from the UK, the USA and Australia, for instance, may not be applicable here or may only be in a very limited way because it is different here. There are many other limitations to most of the research in this area, which include researcher bias, inadequate control for confounding variables and inappropriate control groups, and the failure to control for previous mental health problems. My advice, particularly for those unused to reading medical papers, is to read any such research in a critical, informed and objective way.

The best overall publication in this area was by the Academy of Medical Royal Colleges in the UK which published a systematic review of the mental health outcomes of induced abortion in which they reviewed all of the research evidence available and critically analysed all published research which reached basic scientific standards. The key findings of this overview of all studies were as follows. An unwanted pregnancy in itself is associated with an increased risk of mental health problems. The rates of mental health problems in unwanted pregnancies were the same after termination or after giving birth. The most reliable predictor of post-abortion mental health problems was having mental health problems before the pregnancy or abortion. Women who were pressurised to have a termination and women who were exposed to strongly negative attitudes towards abortion in general and to her personal experience were likely to have long-term mental health problems.

For any and every woman who might seek mental health advice in this situation, it will be the specifics of her individual situation - her distress, history, and personal beliefs and wishes - and often that of her partner which must be listened to and understood. The research evidence is helpful in general but never specific to any individual life situation. The dilemmas for women in such difficult situations will always be painful and distressing. I consider it my responsibility as a psychiatrist in Holles Street not to add to their pain and distress. I hope the committee will be of the same view.