Professor Anthony McCarthy:

I thank the Chairman. I have been a consultant psychiatrist in perinatal psychiatry at the National Maternity Hospital for more than 26 years. During this time, I have seen and been responsible for the care of more than 15,000 women, including those in health difficulties in pregnancy or in the postpartum period. I previously addressed Oireachtas committees on the subject of perinatal mental health. I addressed the citizens' assembly on the protection on life in pregnancy legislation. I am an associate professor of psychiatry at UCD. I am also an expert psychiatric assessor for the confidential inquiries into maternal deaths in Great Britain and Ireland. I thank the committee for inviting all of us to address the members today. Trying to fit my contribution into five minutes will be very difficult. I completely agree with everything that has been said by the previous contributors. I will try not to repeat was has already been stated.

The specialist perinatal mental health services are a vitally important component of our mental health services. Why are they so important and necessary? First, pregnancy, birth and the demands of new motherhood can be seriously challenging for any woman's mental health. Second, a mother's mental health difficulties can have very significant negative impacts on obstetric outcomes and on the baby. It works in both ways.

I will outline the challenges of pregnancy for women's mental health. A mother is 19 times more likely to be admitted to a psychiatric hospital in the first six weeks after the birth of a baby than in any other six-week period in her whole life. It is a particular window, but it does not stop there. Post-natal depression affects 11% of all new mothers - which in one in nine - and is the commonest complication of pregnancy. It is more common than infections, trauma or bleeding. A psychotic illness post-delivery occurs in one in 500 mothers. Although the image of mothers in pregnancy is often of women glowing and contented, in reality pregnancy is frequently an extremely challenging time for women's mental health. Normal pregnancy can be very physically and emotionally demanding. Any women in the room who have had babies will know all of this. While having a child is joyful and meaningful too, many women may have to deal with miscarriage, still birth, haemorrhage or pre-eclampsia, not to mention complicated deliveries, traumatic deliveries, hormone changes, the demands of breast feeding and other complications and demands. That is the physical side.

The psychological and social challenges of pregnancy are considerable for so many. There are unplanned pregnancies, unwanted pregnancies, or the discovery of major abnormalities. There are previous difficult pregnancy experiences and the woman is pregnant again or there have been pregnancy losses before. There may be complications in relationships due to pregnancy or the massively significant increase in domestic violence associated with pregnancy: men are much more likely to be violent or have affairs when their partners are pregnant. Previous psychological or psychiatric issues are frequently exacerbated by pregnancy, and very often new and seriously challenging issues, as listed above, present for the first time. Previous mental health difficulties, such as anxiety, depression, bipolar illness, and post-traumatic stress disorder do not disappear in pregnancy and are often complicated by it and frequently worsen after it unless addressed and appropriately treated. All of these pose considerable risks to the well-being and sometimes the safety of the mother, her baby, and her whole family.

The other side of it is that mental health difficulties affect pregnancy outcomes. Mothers with significant mental health disorders frequently present differently to antenatal clinics, post-natal clinics and emergency rooms. For example, those with depression, psychosis, post-traumatic stress disorder, etc., are less likely to attend for appointments or scans and will therefore have issues missed. Others with major anxiety disorders may present over-regularly and obsessively and may exhibit risky behaviours as a result. I will list the latter afterwards.

Those with major mental health issues can struggle with adherence to advice regarding medication, whether it is for medical conditions such as diabetes in pregnancy, eating disorders in pregnancy, or hypertension in pregnancy, and they are less likely to take vaccines or psychotropic medication for their mental health disorders. Similarly, advice around diet, baby care, and safety are sometimes more likely to be ignored, misunderstood or misinterpreted.

Women with mental health difficulties are also more likely to be victims of domestic violence and abuse.

There are increased rates of termination of pregnancy among women with mental health issues. They are also more likely to have premature deliveries and instrumental deliveries, such as deliveries requiring forceps. Caesarean sections and traumatic births are more likely. It works in both ways: traumatic births can affect women's mental health and women with mental health difficulties are more likely to have traumatic births. Again, it is circular and we must always address both sides.

At-risk behaviours are more common in women with mental health difficulties. I refer to increased rates of smoking, drinking and drug abuse during pregnancy, possibly resulting in withdrawal syndromes among babies or foetal alcohol syndrome. Women with eating disorders may have a very poor diet, be vomiting or use purgatives. Those with anxiety may physically over-check their babies. Women who are highly anxious about their babies not moving may press on their stomachs to check for movement, maybe at 3 a.m., 4 a.m. and 5 a.m. After a baby is born, an anxious mother may wake it up constantly to check on it because she fears it will suffer a cot death. Such mothers cannot deal with their anxiety or obsessional worries. All of these issues are associated not just with obstetric complications but also with subsequent developmental and attachment issues, to which my psychology colleagues have been referring.

There are also the serious mental health issues leading to suicide and infanticide. Suicide is the second most common cause of maternal death in the country, although it is still uncommon. Despite many of the advances in obstetric care, it is still a huge issue. Infanticide, while fortunately rare, is always a tragedy, and the rate is probably underestimated.

The other major mental illnesses that can present at this difficult, key time, including psychosis and depression, have all been shown on the slides. Frequently, these can have lifelong effects, not just on the mother's mental health but also on that of the infants. There can also be lifelong effects on the mother's relationship, her relationship with her baby and sometimes her relationship with other children. She may never quite recover.

What are the functions of the perinatal mental service? Dr. Wrigley has listed these already but I wish to flesh the subject out a little. One function is to assess and advise women referred to the specialist mental health teams with mental health difficulties through pregnancy and the first year after birth. Another function is to assess, diagnose and treat effectively those mothers with moderate to severe mental health problems through pregnancy and the first year after birth, and also to carry out expert risk assessments because the risks are huge.

Treatments may include psychological interventions, social interventions, psycho-education, parenting supports and skills training. Also included are safe prescribing and advice on the safe prescribing of medication in pregnancy and after birth. We do not stop treating people with major mental illnesses with their medication during pregnancy or if they are breast-feeding because the balance of risks is huge in such circumstances. We must proceed safely and be able to give expert advice to mothers and psychiatry services throughout the country, certainly those in our spoke hospitals.

Treatments also include referring for psychiatric admission those mothers who are most at risk and in need of inpatient treatment. As mentioned, the absence of a mother and baby unit for mothers who require admission is the single biggest deficit in our services. We also make referrals to key community services, whether these involve primary care psychology, services in the voluntary sector, Barnardos, mothering skills supports and supports for mothers in the community. We have to be experts. Our social work team is very good at knowing who to refer to outside the hospital.

Assessment of risk also includes assessment of the mother–infant interaction. That has been listed. The team also gives pre-conceptual advice to those mothers with serious mental illness who are considering pregnancy. That may be advice on mediation, or it might be advice for those who have had a traumatic experience or eating disorder. We also provide specialist assessment and advice as per the requirements under the Termination of Pregnancy Act 2018.

I hope the importance of these issues is understood and appreciated. We certainly understand and appreciate them. The development of the specialist teams and services has represented a considerable advance in care. We are so grateful to the HSE and the Department of Health for supporting all that. Obviously, we need a mother and baby unit and would like to develop more support for smaller maternity units. Obviously, we would also like to develop all the services my psychology colleagues referred to, including supports for infants, fathers and families, and to keep growing them. The need is great. The perinatal period is vital. If it starts off well between mothers and babies, and families and babies, and if babies are securely attached at the beginning and their mothers are well, it is such an investment in the lifelong well-being of the children, their families and our society.