Risks to Mental Health: Dr. Anthony McCarthy, National Maternity Hospital, Holles Street

We will resume in public session. I welcome back members and viewers who are tuned in on Oireachtas television. I welcome Professor Anthony McCarthy, consultant perinatal psychiatrist, National Maternity Hospital in Holles Street, to this evening's meeting. Ordinarily, I would read the note on privilege and the Defamation Act 2009. Is Professor McCarthy familiar with that or would he like me to go through it?

Dr. Anthony McCarthy

I have spoken at committees previously.

I figured as much. I just have to check. I am saving everybody having to listen to me say the same thing three or four times a day. I now call on Professor McCarthy to make his presentation.

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.

We do not have any lead speakers as their time ran out so if anyone wishes to speak, they should indicate.

I thank Dr. McCarthy for his presentation. I will start by drawing his attention to his remarks regarding his not wanting to return to an era of illegal back street abortions and infanticide. Any reasonable person would shudder at the thought of living in such an era. Would Dr. McCarthy say that a scenario that is as horrific is that in modern Britain where there is an abortion rate which we estimate is four times that of the Irish rate, if we judge by the numbers of Irish women who go abroad? In that case there is no protection in law for unborn babies up to 24 weeks and no protection where there is any kind of disability, including mild disability. Does Dr. McCarthy agree that also presents an horrific scenario to a fair-minded, reasonable, caring doctor if they had two patients in mind?

Dr. Anthony McCarthy

I raised the matter of infanticide because I am very aware of history. I am also aware, particularly as a psychiatrist, of the history of psychiatry, women who were pregnant, and the control and often the severe things that psychiatry was involved in and responsible for during their pregnancies. I do not want to go back to anything in history. In my practice in Holles Street, my responsibility to anyone who comes to me is to make the best decision for them. When someone comes to see me, I am certainly not there to encourage them to have a termination if, in helping them to come to a decision, that is the worst thing to do. Those circumstances would have a very negative outcome. I am equally not there to bring any personal view to her decision. From my work in the confidential inquiry into maternal deaths, it was evident that so often, when women kill themselves, they do so while pregnant, sometimes with one baby or two, or there is infanticide afterwards. There is a hierarchy of ideals. An ideal is where everyone is happy with pregnancy and everything is wonderful. If I must have a choice between infanticide, back street abortion and abortion in an everyday way, my hierarchy is to go for the least damaging option. That is a personal view. My professional responsibility is to deal with the individual woman before me, and maybe her partner, to help her or them come to the decision that is right for her or them.

Is that a yes or no to the British scenario being somewhat horrific?

Dr. Anthony McCarthy

It is not my responsibility to deal with that. When I see a dead woman, when I read a file of 750 pages that begins with the day she became pregnant, and maybe she wanted to be pregnant, and I know that on the second last page I will read the post mortem report for her, that is what informs my way of thinking about these things.

When Dr. McCarthy speaks of them, is he thinking about two patients including the baby, irrespective of how welcome he or she might be then? Does he feel he has a duty of care to the baby?

Dr. Anthony McCarthy

There is clearly a duty of care to the baby. As the Senator will know, it is enshrined in the Protection of Life During Pregnancy Act, for example.

What about ethically? What is Dr. McCarthy's own outlook?

Dr. Anthony McCarthy

Each time I see a woman in pregnancy, I am involved in having to think of the baby also. Most women who come to see me during pregnancy do so for advice regarding the safety of taking medication. They may have a previous mental health illness and want to know if the medication they take is likely to damage the pregnancy. I have to take considerable time on this. Sometimes I have to look at medication, the women may not be taking it or they might be drinking or smoking and they are damaging their baby. I have to spend considerable time thinking about the damage that maybe done to babies in pregnancy. I have seen women who have taken abortion pills -----

I suppose I mean requests for abortion and the British law. We will move on as we are stuck for time. That really is the big problem with our work. Dr. McCarthy referred to research. We all agree that good quality research is necessary for normal functioning of the law and we cannot ignore it. I draw Dr. McCarthy's attention to the work of Professor David Fergusson. I am sure we agree that he is one of the most highly published mental health professionals globally and that he would not have skin in the game when it comes to coming down on either ideological side. Professor Fergusson has published a piece in 2013 in the Australian & New Zealand Journal of Psychiatry in which he reviewed the four best studies from the place which Dr. McCarthy correctly said is the place to go. Its conclusion was that there is no available evidence to suggest that abortion has therapeutic effects in reducing mental health risks of unwanted or intended pregnancy. There is suggestive evidence that abortion may be associated with small to moderate increases in risks of some mental health problems, and there are particular circumstances in which that might arise, such as previous mental health history. That being the case, does Dr. McCarthy agree that it would be unconscionable that any jurisdiction providing abortion would not be in the business of checking if a woman has a prior mental health history, that it would be under a duty to advise of the potential risks if there was any evidence of mental history, and that should be mandatory practice across the board?

Dr. Anthony McCarthy

The paper to which the Senator referred is a very good paper. It agrees with the basic assessment point I made, namely, that the mental health outcomes after termination or pregnancy are similar. In both cases, the risk is increased. Pregnancy itself is a risk to mental health. The reason I have a very busy service in the National Maternity Hospital is because of the mental health problems associated with the complications of pregnancy.

If a woman has a termination, she is equally likely to have mental health problems and no less or no more than a woman who does not have a termination and goes on to have a baby. Both are vulnerable. It is the single most vulnerable time in a woman's life. A woman 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 life.

There are certain circumstances, in particular in the case of women who have previous serious mental health problems, where women are more vulnerable to having problems whether they have a termination or go on to have a baby.

Professor McCarthy referred to it by implication.

Dr. Anthony McCarthy

There is an idea that everybody should have counselling and be assessed for serious mental health problems. One of the major challenges in my clinic is that many women come to my service who do not want to have any counselling whatsoever. First, what is a mental health problem? Is it stress after an exam when I was 15? Is it somebody who had anorexia? Is it somebody who had a major depression after bereavement? Something may have happened ten or 15 years ago. Are we going to insist that a person has to talk to a counsellor or expert or psychiatrist in some form? That would be absolutely impossible. We know from our work that if somebody wants to have counselling, he or she will get counselling.

We are shot for time. Counselling is one thing. Given that there is at least one life at stake, and potentially two, the gravity involved, the culture of informed consent which applies in other areas of medicine and the duty of care involved, surely it is not excessive to expect a basic investigation to see what type of person is before one?

I refer to a study from Professor Fergusson. The ground has moved. In 1994, the Royal College of Psychiatrists found that the risk to psychological health from termination of pregnancy in the first trimester was much less than the risks associated with proceeding with a pregnancy which is clearly harming the mother's mental health. Professor Fergusson described a big shift from that ground of seeing potential benefits to a situation where nobody is now talking about the mental health benefits of abortion. Rather, it is case equal. The only question is whether it causes mental health problems in certain cases. He is very cautious in his studies. In 2008, he noted that the specific issue of whether induced abortion has harmful effects on women's mental health remains to be fully resolved. There is a movement away from seeing any kind of benefit on mental health grounds.

Dr. Ruth Fletcher argued that the concept of health should be used to encompass situations like the claim for abortion on the grounds of foetal anomaly or cases of rape, and that health could be used as a grounds to avoid legal stigmatisation. She stated such circumstances could contribute to a risk to health. I presume she was talking about mental health.

The work of Professor Fergusson, which has analysed other work, seems to suggest that one does not go there on mental health grounds. Would Dr. McCarthy agree?

Dr. Anthony McCarthy

Some 20% of women will have a mental health problem at some stage in their lives. The figure is lower in men, and there is a very interesting discussion as to why that is. Some feminists would say that women's mental health problems have been caused by men. Women come to psychiatrists-----

Let us say some men.

Dr. Anthony McCarthy

Women go to psychiatrists. Men go to prison with their violence. There is almost an attitude nowadays that no matter what happens in people's lives they need counselling. It is rubbish to suggest that someone who has been bereaved needs counselling. Most people, following bereavement, want to be silent or talk to their partner, spouse, mother or friend. They do not need counselling. After major trauma there is a notion that people need to be debriefed in some way. The reality is that often a debriefing does more harm than good. People who want counselling will seek out a counsellor and talk. People who do not, but are forced to, will tell a counsellor nothing. The session will be empty and useless and the person will resent it. In fact, one may do people more harm by forcing them into a process which demeans them.

The women who come to see me in Holles Street for advice want that advice and, therefore, are very open and tend to bring up all of the key questions. As the committee knows, it will be a very long time before we have enough psychiatrists in Ireland to see everyone. I currently have 1.5 days a week in Holles Street and have two colleagues in the other Dublin maternity hospitals. There are no such specialists anywhere outside of Dublin. The idea that women would have to undergo counselling is impractical. More truthfully, the idea that every woman who ever had a mental health problem should have that assessed by a psychiatrist before she can have a termination is an insult to women.

Is Professor McCarthy agreeing with me that it would be wrong to invoke health as grounds for termination? Professor Fergusson said his conclusions have important, if uncomfortable, implications for clinical practice and the law in its interpretation in jurisdictions which require abortion to be authorised on medical grounds. He went on to state his view was that the growing evidence suggesting that abortion does not have therapeutic benefits cannot be ignored indefinitely and it is unacceptable for clinicians to authorise large numbers of abortions on grounds for which there is currently no scientific evidence. Does Professor McCarthy agree that there has been a shift away from invoking mental health?

Dr. Anthony McCarthy

I understand why Senator Mullen is asking that question.

Do not mind why I am asking it. The question is important.

Dr. Anthony McCarthy

Should we, therefore, insist that before any woman becomes pregnant she sees a psychiatrist to have her mental health assessed?

Could Professor McCarthy repeat that?

Dr. Anthony McCarthy

Should we insist that a woman should see a psychiatrist before she becomes pregnant in the first place? That might be equally damaging to her mental health.

Yes. In other words, mental health is not to be invoked. Does Professor McCarthy accept what Professor Ferguson said?

Dr. Anthony McCarthy

Did Senator Mullen hear my answer? Does he realise what he answered? I said we are accepting that termination of pregnancy and pregnancy are both serious threats to a woman's mental health. Therefore, we should develop a system where women, before they get pregnant, should see a psychiatrist to have their mental health assessed before they can have a baby or termination.

Professor McCarthy is arguing an absurd proposition-----

Dr. Anthony McCarthy

Exactly.

-----for rhetorical effect. He appears not to be uncomfortable with the question I have put.

Dr. Anthony McCarthy

I am not uncomfortable with the question. It is a ludicrous idea to suggest compulsory counselling. The term "mental health" is broad. It includes mild anxiety, a phobia, serious depression-----

Professor McCarthy should not blame me. That is the British abortion law. I asked him earlier if he had any problems with the British abortion law and he declined any expression of disapproval. Do not blame me for the British abortion law.

Dr. Anthony McCarthy

I am not.

I thank Professor McCarthy.

I have allowed you 13 minutes.

I hope people found it useful. We could do with 30 minutes each.

Excuse me. I have given you more time. I think you have asked questions that need to be asked. I appreciate that. Thank you.

I thank Professor McCarthy for his presentation. I found it fascinating when I read it yesterday. I was particularly struck by the history of infanticide in our country. I was not aware of it and it is another indicator of what a dark place this country was for women for so long. It is to be hoped we are involved in a process which will move us all to a better place. I thank him for that.

I am tempted to repeat one line from his presentation, namely, "We cannot wish abortion away". Some of us may need to think about that. He said that fears about the enactment of the 2013 Act would lead to significant numbers of pregnant women trying to fool clinicians into granting abortions by threatening suicide have not been borne out in real life and were never going to be. Could he speak a little more about that, as a professional in the area?

Dr. Anthony McCarthy

That is not part of my presentation from today. When I spoke before the Seanad in the sessions that led to the development of that Act, I know people were saying there would be bus loads of such people. I remember being asked if buses of psychiatrists would be coming in from elsewhere or women would be queuing to come to psychiatrists and lie to us or fool us by saying they are suicidal, etc. I put it on the line and said it was ludicrous and it would never happen. In the years since the Act was established, I have seen one woman in Holles Street in that circumstance.

There was the idea that women would somehow invent these stories but the women I see are genuinely distressed, whether they have a termination or keep the baby. It is a genuine and real problem. They are in desperation by the time they come to see somebody like me. There is the phrase, "Sometimes the world is more full of weeping than you can understand", and it might be over my office door because of some of the stories I hear. The idea that pregnant women would come in to see psychiatrists to fool them into thinking they are suicidal is not how it works in the real world. It was somebody's fantasy that this would happen.

In the real world I am very conscious that right now women must travel and leave the country if they need a termination. Is that a good thing?

Dr. Anthony McCarthy

How could it be a good thing? I see women who come back afterwards as well, and they have a level of distress. The committee has heard the stories and I do not need to repeat them. How could any human being react listening to women describing taking the boat rather than the plane and bringing the foetus in a bag? I will sometimes have seen them before the termination. They will show love for the foetus and have a photograph of it. It is a baby they loved but this was the only way for them to deal with the matter. They are hurt, outraged or upset that they had to go to the UK.

Is it not horrific that women have to face that at this point? How is the 2013 Act working? I know this was not part of Dr. McCarthy's presentation but it is relevant for decisions we must make on legislation. Do the current procedures under the Act provide dignity to patients? Are they workable across the country? Do they ensure pregnant women and girls who may need an abortion due to risk of suicide would be able to access the service? Are they necessitated and could another pathway be considered?

Dr. Anthony McCarthy

As the Senator was speaking I was thinking about what Senator Mullen asked. My views on abortion, to a certain extent, do not matter as the women I see who are going to have an abortion are having them anyway. It is such an irrelevant question for me in my practice. The women will have it here, buying their tablets on the Internet, or they will travel. I do not even think about what is happening in the UK except that people have to travel there. They are losing their babies anyway. It is happening.

To answer the Senator's question, as he knows there have been very few such cases. A woman has to see two psychiatrists, who have to agree, and one obstetrician. If everybody agrees on the case, that is it. It is a problem and I know cases have been highlighted where things went very poorly. Some of the psychiatrists who saw patients in those circumstances had never previously dealt with a mental health problem in a pregnant women or seen women in those circumstances. Some of the decisions made led to court orders and various other processes because those who did the assessment never did the work in a daily way before. Of course, there is no adequate provision of psychiatry services around the country.

Fortunately, there is a perinatal mental health strategy that is about to come out and it recommends that there should be full-time psychiatrists in every large maternity unit in the country. It argues there should liaison psychiatry at least part-time in every maternity hospital around the country. It is coming. Fortunately, I was right in that the demand was never going to be there; it has amounted to a trickle. Some of those women have had very faulty assessments as those who saw them had no training in the field.

I thank the witness for the presentation. When I read it I could tell how person-centred it was and I appreciated how human it was as well. I am sure that translates into how the witness treats women when they come to him. I got some solace from that in reading the presentation. Senator Gavan posed the questions I wanted to ask so I will make some comments instead.

Senator Mullen upset me when he used the words, "what type of person is before one". I am not really sure what that meant. The Senator said in reference to someone arriving and having mental health issues, and whether the person would have had mental health issues before arriving. The phrase used was "what type of person is before one". I do not know the Senator's intent. I took it to mean that if a person has a mental health issue before coming pregnant, somehow this would undermine the woman's capacity, as a person, to have autonomy and view of life and who she is. I did not appreciate it. As a woman and mother who sought help during my second pregnancy from the witness's counterpart in the Rotunda, I found the comment very distressing. I will stand corrected if the intent was not there but I suggest that the Senator read the debate. He referred to "what type of person is before one". She would be the same person and the continuity remains the same.

If caring about women entering an office and women's health in general is ideological, I thank the witness for his ideology.

Does Senator Mullen have a point of order?

I ask you to please impose some kind of structure and fairness here when a person is attacked, as I was when seeking to tease out matters. I thought I was being reasonably clear. Senator Ruane has responded in a personal way and implied some kind of motivation or attitude in me that certainly is not there. How can we have a fair process here if, once one has finished trying to respectfully elicit information and answers, one is attacked in a frontal and emotional way by a colleague? It is making a farce of this procedure. Anybody listening would know of my bona fides in my line of questioning. It would be a great regret to me if Senator Ruane was upset but I cannot remember anything I said that would have been objectionable. I was trying to deal with complex mental health grounds for abortion and people with a history of mental health issues being particularly vulnerable.

First, I clarify there was certainly nothing of bad intent in what I say. Second, I should not need to make such a clarification. To be taken on in this way by a colleague with no chance other than by seeking a point of order to respond does not auger well for this process. We have had problems of this kind on countless other occasions.

The Senator's comments are very much noted. The Senator said what she had to say.

I would appreciate your ruling on it.

There is no ruling to be made.

Suppose I had gone from the room. The media would be left with some notion that I had some kind of bad attitude.

I was very aware of the fact you were in the room, which is why I allowed the Senator to make a comment and you to respond. I will not get involved.

You could be more generous in your defence of every member's right to try to tease out complex matters in a respectful way without being sniped at by colleagues. I never do it.

I reiterate the comments I have made on numerous occasions. I want this to be a place where people feel they can make comments and ask questions. It is a very difficult and divisive matter. In so far as it is possible for me as a referee, I have allowed the process to unfold. Unless people stray into an area that is not allowed-----

I think the Chairman allowed it. She saw where it was going. It was very personalised.

I did not see anything of the sort. I have given the Senator the opportunity to respond but it seems I am still wrong. Could we move on?

Up to now we could not apparently use words like "mesmerise" but when a person on the committee wishes to express her distress-----

Senator-----

The Senator has a problem with a woman making such an expression. We are talking about the experience of pregnant women. I happen to have been one of them and my comments are valid.

Please, if you want to have a row, take it outside.

Only one of us sought a row. I only sought to defend my good name.

I directed that to Senator Ruane.

If you were not speaking in the plural, that is okay. Thank you.

I call Deputy O'Brien. Sorry, it is Deputy O'Reilly. I wrote down Deputy O'Brien, I wrote down the wrong name for some reason.

That is fine.

To return to one of the points made by Senator Ruane, I do think there has to be a certain amount of respect given to those of us on the committee when we are discussing pregnancy related issues who have had that very personal experience. I found the content of some of what was said quite disrespectful. I do not intend to get into a row with anybody about it. In fact, the more people who see it, the more the disrespect is evident.

With regard to the perinatal mental health strategy, we appreciate that it is to be introduced. That will require a significant amount of investment and upskilling of personnel. It is also going to require access right across the country. We would welcome the fact that it is on its way but what we are discussing is the grounds as laid down by the Citizens' Assembly. One of those is the mental health of the pregnant woman. As things stand we are clearly struggling in that area. It is true to say there is a huge amount of compassion and it is radiating from the evidence we have heard. That is very much to be welcomed.

Does Dr. McCarthy agree with me that the added stress and trauma for a pregnant woman in terms of what the 2013 Act places on her is compounded by the lack of resources? While we are considering the issue around access to termination on the grounds of mental health, we must also consider the resources and the implications for that. That is going to be important for us.

We are considering risk. I have asked this question of every single witness. I appreciate that I usually get the same answer but it is important that we have it on the record. My understanding is that it is quite tough for us as legislators using legalistic terminology to hand the medical professionals a piece of paperwork and ask them to make medical decisions based on it. We use terms such as "grave risk" and "serious risk". Will Dr. McCarthy indicate whether such terms are in use in the medical profession or is it more likely that there is just risk, that there are not categories such as "grave" and "serious"? What kind of terminology is used? I am conscious that what we are doing is trying to devise a legalistic framework, but when that is finished, we hand it to the medical profession. How easy will it be to translate that? I am conscious of the 2013 Act and the necessary complications that arise out of that, and the fact that all of the available evidence suggests, as was pointed out by a lot of people in advance of it, that it is fairly unworkable for most people. We know the result of that. We use legalistic terms in listing the gradation of the risk. Is there anything we can do to help to translate that for practical use?

Dr. Anthony McCarthy

First, I will make a brief response to the first part of what Deputy O'Reilly said, which echoed what Senator Ruane said. Just because a woman has had a mental health problem in the vast majority of cases, it does not in any way affect her capacity to make decisions for herself. That is the response to the question on capacity. In the vast majority of women it is not a question of capacity whatsoever. I wish to make that point.

As regards the 2013 Act, as I said at the outset, before the legislation was enacted, the reality is that for the vast majority of women who are depressed and suicidal in pregnancy, they do not want a termination. However, the vast majority of women who want a termination are not depressed. They do not need to see a psychiatrist. For the majority of those women who are depressed in pregnancy and want a termination, they are not going to go through an Irish process. Why would they? They are going to go to the UK anyway or they are going to order pills over the Internet. Even if there were psychiatrists all over the country, most of them do not feel they need to see a psychiatrist. Most of them do not think they need to see one psychiatrist let alone two psychiatrists. That ill was the result of saying that, whatever about general medical illnesses, in terms of psychiatry it was not going to be about serious risk or moderate risk but about one issue only, and that was the question of suicide, the probability that a woman was going to commit suicide, and if termination was the only possible solution for that, then it followed. Therefore, it is no wonder that for the vast majority of women in this country it is an irrelevancy.

Suicide at least was at the extreme end. On the idea that psychiatrists or anybody - psychologists, counsellors or parliamentarians - would discuss the gradations of a woman's mental health, that would be an impossible one for clinicians. When we are talking about mental health, we can accept a clinician trying to make the best estimate possible over a suicide risk, but bringing it down to an assessment of a woman's mental health, bar excluding the very small group of women who may not have capacity, for the vast majority of women the idea that we could have some system where they all had to go to see a psychiatrist to have a score on their mental health is not going to work.

I thank Dr. McCarthy for coming before the committee. I am aware of a number of stories where abortion turned out to be a bad decision for the woman involved and where it carried long-term psychological after-effects. Many personal stories have been told to that effect. One well-known public story is that of Miss C who was brought to England as a minor for an abortion and then spoke publicly about how much she regretted the abortion. Sometimes a person thinks they know what is best for the vulnerable person in question but the decision turns out to be wrong.

Does Dr. McCarthy think women considering abortion, in particular those predisposed to mental health issues, should be told about the possible negative consequences of abortion before the procedure takes place? Am I correct in saying that does not happen at present?

Dr. Anthony McCarthy

I have seen women who regretted having abortions. I have seen women who have had long-term mental health problems following abortions. Every time I think about that, I think of particular individuals. I have seen huge numbers of women who have had abortions and that has not been the case.

The vast majority of women are aware that an abortion could be negative to their mental health. The vast majority of women struggle with that and they are ambivalent. Those who have mental health problems already are the ones who are most aware. They are also aware that if they go on to have a baby, there is a risk to their mental health.

I was perhaps being slightly mischievous with Senator Mullen in asking whether we should get women to see a psychiatrist before they ever get pregnant. To a certain extent it is the same question. There are women who regret not having had a termination. There are women who regret the failure of the morning-after pill. There are women who regret both. Most people have the knowledge that an abortion may be damaging to their mental health. That is often the reason for their ambivalence. In terms of the idea that there is a message out there that abortion is good for one's mental health always, with happy smiling faces, that is not how it is on the ground. There will always be people who will regret serious decisions. Becoming pregnant is a very emotional time. A straight answer as to whether women should be aware there are potential mental health difficulties following abortion is, yes, of course, as there are after pregnancy.

My question is whether they are being made aware of it, as such, to Dr. McCarthy's knowledge.

Dr. Anthony McCarthy

I do not work in any pregnancy advice centre. I do not do that. The women who come to me are aware from the beginning. They are seeing me because of concerns about their mental health or because they have a mental health issue already or they are incredibly distressed because they have just discovered they have a baby with a fatal foetal abnormality or whatever the circumstances might be. They are very distressed already, so I am there helping them to weigh it up, but those who are seeing me know that already. I cannot say what happens in every single pregnancy advice centre but there certainly should be a general awareness that an abortion presents a risk for the woman.

It is a pity the people who were quoting the Dr. Fergusson study have left the room. Dr. Fergusson clarified the position on his research on our national broadcaster four years ago. The man who is continually quoting him says the interpretation of Dr. Fergusson's data is that abortion is bad for mental health. Dr. Fergusson stated that he had completed a review of the evidence and his view was that there was no evidence that abortion mitigated any mental health risks of unwanted pregnancy. That was based upon a review of the limited research and he said that the first point was that the research was not particularly good and any conclusion drawn should be made cautiously. That was his major conclusion; he could not find any evidence of benefits. He went on to say that abortion does not improve mental health of women and, has no mental health benefits and poses more risks for unwanted pregnancy. That is on the record. Dr. Fergusson also said that research has found that abortion has no therapeutic value in reducing the mental health risk. Instead, the evidence suggests that abortion may be associated with an increased risk of some mental health problems. Dr. Fergusson said that statement was true. He found that he compared women who had an abortion with equivalent groups of women who had unwanted pregnancies or intended pregnancies, the women having abortions had slightly higher rates of mental health. Basically, what he said about his study was that there are limitations in it. My take is that Dr. Fergusson is not happy about the conclusions that have been continually drawn by certain groups on his work to be drawn on his work. It is important that when someone is being quoted as saying X, but is actually saying Y, then it has to be called out. Anyway, I thank the professor for coming in to us. It has been helpful and in particular his statement has been helpful to me.

The Child Care Law Reporting Project published known facts recently in the case of a pregnant girl who sought an abortion under the Protection of Life During Pregnancy Act on the suicide ground. Instead, she was briefly detained under the Mental Health Act. Ultimately, she was denied the abortion she requested. It appears that, instead, her pregnancy was terminated via early induction or delivery. This is being claimed by some groups as a good outcome. These are people who want to retain the eighth amendment, even though it was determined that it was indeed her informed decision to end her pregnancy. Does this raise any concerns for Professor McCarthy? As a psychiatrist, is he concerned that medical professionals might err on the side of caution and end up detaining women under the Mental Health Act if a health ground were placed in law? Does Professor McCarthy think that forcibly detaining and interring women is a good solution for health professionals and women? How could we mitigate that risk?

Dr. Anthony McCarthy

I will reply first to Deputy McConnell's question about the Fergusson report. It is a pretty good study but it has major limitations. As I highlighted, almost every study has serious limitations. That is why the meta-analysis or systematic review done by putting everything together came out with the conclusions. The conclusion of that study and the first part of what Senator Mullen said is that abortion is not good for women's mental health - but neither pregnancy nor marriage are good for women's mental health either, as we know. We have to know these things.

I heard the same interview with Dr. Fergusson on "Morning Ireland" on RTÉ Radio 1 when he said that his study was being selectively quoted. There was nothing actually that I could hear from what Senator Mullen said that he was selectively misquoting. Dr. Fergusson said we should not take too much out of the study. He said there were major doubts and gaps.

In my opening statement I referred to the notion of control groups. This is the single biggest flaw. I am unsure how many of the scientists here do research. Anyway, what do we mean by control groups? I was trying to think of an analogy. Let us suppose I did a study on people who get lung cancer and I examined whether they got stressed and whether that caused the lung cancer. Let us suppose I asked all of them whether they got stressed before they got lung cancer. I would find that 80% said they were stressed before they got lung cancer. We might think in consequence that stress equals lung cancer. However, if we have not compared those who smoke to those who do not smoke, we completely miss the key fact. Many of these studies are not looking at comparing only women with unplanned pregnancy or women who have been pressurised to have a termination. In other words, it is not comparing the key or important variables at all. It is altogether selective. It does not even examine the gestation of the pregnancy. Many other factors are involved that are missed in the vast majority of studies. Dr. Fergusson was honest. He pleaded for people not to quote him suggesting the conclusions were absolute fact. He was being misquoted. The actual words Senator Mullen used today are in his study, but there are major flaws to it.

Deputy McConnell asked about a particular case. Obviously, I cannot talk about specific cases, but a woman cannot have a termination of pregnancy past 24 weeks. There is a responsibility for all doctors to consider the health of the foetus. Of the few cases that have arisen, I am aware of one case where a woman was actively seeking a termination and was detained. Actually, she could not have a termination anyway, because she was past that term.

We only detain a woman if she has lost her capacity or if she has a mental illness. I was not involved in that case but, as far as I understand it, if the woman did not have a mental illness, then it was absolutely wrong to detain her. First, I have no doubt that those involved in the circumstances almost certainly do not work in this area. Second, they were highly anxious. If a woman is hitting her stomach with her hands, literally pounding into her stomach, and saying that she wants a termination of pregnancy, then people will sometimes not be able to stand back. They may panic and take the view that they must do something and then decide to use the Mental Health Act. Psychiatry has a dangerous history in that regard, one I am acutely aware of. Anyway, that is a major error. If a woman does not have a psychiatric illness – this girl clearly did not and that is why the court lifted the order shortly afterwards - then it was a major mistake to detain her in the first place.

A point was made earlier about the abortion rate in the UK being four times as high as the Irish rate. Did someone get clarity on that in my absence? I thought we heard earlier today that that there is no such thing as data in areas that have no abortions or where people seek illegal abortions. That was being quoted here but we do not actually know the official rate. It is important to clarify that point on the figure. Technically, we do not know the rate here. It is being bandied around here.

If there is any clarification that can be brought to bear on it based on what we have heard thus far, I will highlight it.

There are views from people we have heard from.

I thank Professor McCarthy for his paper. I too found it interesting. I could see the humanity in it as well, something I appreciate.

Professor McCarthy quoted from the Academy of Medical Royal Colleges in the UK. He noted cases of women who are exposed to strongly negative attitudes towards abortion in general and whose personal experiences are likely to have worse outcomes. I have said before at this committee and elsewhere that I accompanied a group. It was around the time of the Protection of Life During Pregnancy Bill. I went to Liverpool Women's Hospital with Doctors for Choice Ireland. It was specifically around the area of fatal abnormalities. I got some indication of the way women were treated in that hospital and environment. They were treated with great humanity and care. That made me feel very ashamed because they did not get that here. One person who was on that visit asked whether there was a difference between Irish women and women from the UK in how they were treated or how they felt. The instant response from the people who took care of those women was that what differentiated Irish women was that they felt judged. I suspect that is exactly the same whether it is a fatal abnormality or a requirement to leave the jurisdiction. They feel different by virtue of the fact that they were forced to leave the country.

Those strongly negative attitudes and presumably the very fact that people have to leave the jurisdiction would feed into those poorer outcomes. Would that be a fair assumption and does the witness see people when they come back who would express views like that afterwards?

Dr. Anthony McCarthy

In terms of the evidence, the research papers that have highlighted that have been predominantly from the United States. We have to be careful about what we might think as human beings and what research evidence states. The research evidence that is based on tends to be from the United States where people are going into clinics where there might be crowds outside abusing them as they go in and where there may be threats as they go in. The research evidence is in that. That is the general attitude coming across. In terms of the individual ones it is very clear that particularly pressure from a spouse to have a termination can be a problem if an individual does not want one. Equally, a very strong family opposition to it, when a person still goes ahead, can be damaging. That is at a very personal level. I am not aware of any study that has been done specifically looking at the Irish question. Do I hear people in my office saying that? I do not see that many coming back. One woman said it was bizarre, it was dreadful, here she was terminating her much wanted baby and she thought it was going to be the worst day of my life but compared to the many weeks beforehand it was an extraordinarily kind occasion. She said it was almost lovely the way she was cared for and looked after, and people were so non-judgmental. She was comparing it specifically to how her family had responded to it. Yes, at human level I can say that. I do hear those stories but the research evidence is from America.

Dr. McCarthy says 500 women a year attend the clinic. Is that number broken down into those who are pregnant? Does the witness look after women in the year after pregnancy or what part of the health service would look after women?

Dr. Anthony McCarthy

I see them for up to six months after the birth of a baby. With the small size of my team it would be impossible beyond that. We also sometimes see women even before pregnancy particularly if they have a major mental health problem or mental illness and are concerned about pregnancy and concerned about the medication they are going to have. We do see women even before pregnancy or maybe they have had some particularly difficult stillbirth before or a sudden infant death. Breaking it down, there are so many different categories that I would not give the figures here. We will see people for up to six months afterwards including if it has been a miscarriage or a termination or a stillbirth. We will be compassionate about that as well. It does not necessarily stop exactly at six months.

Some of the 500 women would be referred to Holles Street or would they be patients of Holles Street?

Dr. Anthony McCarthy

They would be patients of Holles Street.

Right, okay, that is fine.

Dr. Anthony McCarthy

With 9,500 deliveries per year we are extremely busy and if I were to take women from outside of Holles Street I would never go home.

Thank you. I call on Deputy McGrath, who has six minutes.

I thank Dr. McCarthy for coming in. I have to take him up on something he said earlier about people saying back in 2013 or 2012 in the committee that I was a member of that there would be bus loads of psychiatrists coming in to allow abortions if the 2013 legislation went through. Can the witness enlighten us as to who claimed that or is he quoting from the records? I do not remember anyone claiming that at the committee at that time.

Dr. Anthony McCarthy

Truthfully, I cannot remember who said it to me but I do know it was said in the room when I was there.

In the committee?

Dr. Anthony McCarthy

In the committee.

In the hearings?

Dr. Anthony McCarthy

Oh yes. In either the first or the second set of hearings. I cannot remember which but I was invited to both.

Perhaps Dr. McCarthy could check the record and respond to me later.

Dr. Anthony McCarthy

I will.

I was a member of the committee and I do not remember it being said.

We can check that.

There was no evidence for the suicides. It was remarked that threat could be grounds for abortion. Roughly, I believe, seven lives have been lost, seven too many as far as I am concerned, on the alleged threat of suicide. The floodgates did not open, to use Dr. McCarthy's own words. On whether the abortion happens here or abroad, it was put to the witness that in Ireland the much lower rate suggests the law has a protection effect. Does he accept that?

Dr. Anthony McCarthy

I do not understand the question.

The witness was claiming it was irrelevant whether the abortions were here or abroad. I am putting it to him that is an indication that the legislation here has a prohibiting effect on the number of abortions. When compared with the numbers in England, and I am not going to get into a debate with Deputy O'Connell about the numbers, they are much higher in England than here.

Dr. Anthony McCarthy

I am not an expert on the number of women in Ireland having abortions. That is not my job. My job is to see women-----

Would the witness speak into the microphone please?

Dr. Anthony McCarthy

I am not an expert on the numbers issues at all. I was not aware that there were any great numbers. I also know that the numbers are unreliable anyway because I see women sometimes who have had terminations at home taking tablets and I know women who have gone to England for a termination and given an English address. I am not sure how important numbers are in all of this in terms of the reality of the work that I do. The reality of the work is that the women I am seeing who decide to have a termination of pregnancy - and many as I say do not - are going to the UK to have it. I have not yet met a woman who has not had a termination because she had to stay in Ireland. I have not had that experience. I know of other situations where women have not been able to afford to go to the UK and I know of one case in particular. I know there are issues with children or with refugees but it has not been a personal experience of mine. All I can tell the Deputy is my own personal experience and what I come across. I am not sure what the Deputy's question is that would specifically address that.

For clarification, I am afraid I may have misheard Deputy McGrath. Did the Deputy say, and maybe I heard it wrong, that seven lives too many were saved?

I do not think he did.

(Interruptions).

I am not sure that I heard it right.

No, the Deputy did not. I did not say that. I would not say something like that.

Seven "whats" too many?

Sorry, we can clarify it if there is a requirement for that.

Professor, I know that the situation can arise during pregnancy where women suffer depression or mental health disorder and that we need to ensure that women are cared for in the best way possible. Would the witness agree that the optimal outcome would be that a woman, a mother, gets the support and treatment that she needs and that both she and her baby are safely delivered of the pregnancy?

Dr. Anthony McCarthy

If that is possible.

The professor's comments are interesting. I respect totally his professionalism but was he being flippant with his comments about mental health because we had a witness in last week who said that every man, woman and child's mental health was affected by the amendment? Can I assume Dr. McCarthy was being flippant when he referred to mental health and marriage? Was the witness just being flippant when he spoke about the mental health of people who are married or pregnant or not pregnant? I am a proud parent of eight children and I was put through all the pregnancies with my good wife and indeed both Senator Mullen and myself were the result of pregnancies ourselves, thankfully.

(Interruptions).

I do not scoff and laugh at anybody else. It is totally ignorant.

In fairness Deputy McGrath-----

It is ignorant and disparaging.

People felt that the Deputy was making a joke.

I did not make a joke. I would like to continue without the sideshows and the ignorant comments, please.

Could we please let the Deputy have the floor?

This is why the committee is such a charade. I do not interrupt anyone. It is a total charade. I am on several committees in this House and none of them behaves in this way. None of them. I am in and out of the finance committee all day.

Deputy, sorry, just one second. We will come back to housekeeping issues in a few moments. Please ask the questions that you want to ask and let the witness answer them and we will move on.

I did ask. I asked if the witness was being flippant.

Will the Deputy allow him to answer?

I was just clarifying but people think it is very funny. I am clarifying that he mentioned marriage having a bad effect on mental health. Maybe it has on some but not on the vast majority of married couples in this country.

Dr. Anthony McCarthy

I was making a flippant comment.

The witness was being flippant.

Dr. Anthony McCarthy

Of course. I was making a flippant comment. When we look at what is good for people in their lives - some are looking into it - we note that pregnancy in general is not good for women's mental health. Termination is not good for women's mental health, but it is no worse and no better than pregnancy. I was flippantly adding that if we were to have women assessed for their capacity before consenting to decisions in their lives, be it to have a termination, get pregnant in the first place or even get married, all of which have negative consequences for them, the psychiatrists would be very busy. The research does show that the mental health of women in general - not in the case of the Deputy, obviously - is best when they are single and worst when they are married. Men's mental health is best if they are married and worst if they are single. That is the research evidence.

Where does that evidence come from? Will Dr. McCarthy clarify where he got it from?

That is very interesting, but it is for another day.

It has been given. From where did Dr. McCarthy get it?

As I said, it is very interesting, but it is for another day.

I do not find it interesting; I find it strange.

We are not going to get into a debate at this committee about whether marriage makes one happy or unhappy.

I find it a bit bizarre.

We are talking about the topic of abortion. In fairness to Dr. McCarthy, he made a light-hearted comment, as did the Deputy. That happens in life. We will move on.

I did because-----

We know that it is not a light-hearted topic.

That is why I am surprised-----

The light-hearted comment was well meaning, with which I do not believe there is any problem. The Deputy did the same. Can we move on to the next person, please?

With respect, I asked Dr. McCarthy to clarify whether he was being flippant. He has now said he was. This is not a matter on which to be very flippant.

In fairness, I have to defend Dr. McCarthy, although he is well able to defend himself. He was making a light-hearted comment in difficult circumstances. There are many people who would say that the day on which one cannot make a light-hearted comment in very difficult circumstances is the one on which one is really finished.

I am one of those.

I call Deputy Bríd Smith to ask her questions.

I will definitely read the studies of infanticide. It was amazing to compare the lives of women and what it was like to live in Ireland with an unwanted pregnancy before the 1967 Act with what it was like afterwards. Dr. McCarthy rightly referred in his presentation to the 1967 Act as the Irish abortion Act. Without it, we would never have had abortions in this country. It was illustrated that this was an island on which there was no access to abortion services. There is a limited number of abortions. There are variations on a theme across Europe. If one were in Poland and needed help, one could get on a train and travel to Germany or Austria. In Ireland, being an isolated island that was poor for a long time and which is now quite wealthy, we are still in the Dark Ages. I will definitely read the studies and thank Dr. McCarthy for pointing me in their direction.

Anecdotally, I believe there have been more ways than one to skin a cat in the history of this country. I was on a walking holiday in County Donegal learning the names of plants in the Irish language when I noted there was a lovely little plant that traditionally had been picked to make a tea in order to abort an unwanted pregnancy. This has been occurring for hundreds of years. The plant had a beautiful old Irish name and I brought home lots of it if anybody wants to have a cup of tea. I am letting anybody who needs help know about it.

I want to quiz Dr. McCarthy about the Protection of Life During Pregnancy Act and the barrier of two psychiatrists and an obstetrician a woman has to get through if she needs an abortion because she is suicidal. Dr. McCarthy has mentioned that most psychiatrists, or some of them, had never done this kind of work. By that, I believe he meant they had not seen pregnant women with mental health issues. That is the professor's job and he has been doing this work in Holles Street with hundreds of women every year. The psychiatrists who are now doing this work under the Act would not have been used to it. Is the Act fit for purpose if practitioners such as psychiatrists are doing a job they never did before in very serious circumstances involving women whose lives are at risk? Obviously, if one does a job for a long time, one gets used to it, but if one is starting from a position in which one is not used to dealing with pregnant women with mental health issues who request an abortion because they feel suicidal, it is a different matter. Does Dr. McCarthy believe the Act is fit for purpose if the two psychiatrists whom a woman must see are not used to the work, given the stretched resources available in the country? Do the psychiatrists have a choice in doing that work? Are they forced to do it? Are they told on the day by the HSE that they must interview two women who are suicidal because they are employed by it? Can they opt out if they do not want to do that work?

Rather than going to two psychiatrists and an obstetrician and having to go through the hoops and over the jumps the ridiculous Act has forced on women with mental health issues, would it be easier for a woman to travel to Britain to have an abortion? Who, in the main, has to go through all of this? Is it girls? Is it women who are below the age of independence or women who are not capable of having financial independence? Is it very poor women? Is it refugee women, in particular, or women in direct provision accommodation who cannot leave the country? Does this reflect badly on the country? As well as penalising all women by not giving them a choice in respect of their own reproductive systems, we further penalise a cohort of women, particularly those who cannot leave the country because of their immigration or refugee status.

Dr. Anthony McCarthy

There were a few questions, but I will start by talking about having a sense of humour. I am sorry that Deputy Mattie McGrath has left. Having a sense of humour is very important in my job. After talking about a very distressing matter, being able to share a joke and a laugh is sometimes one of the best things we can do. Even laughing and joking after some painful losses, including pregnancy loss, is part of the process. It is a little like being at a funeral; people will laugh and joke. That is part of the human response in situations such as this. It is healthy rather than something about which to be offended, I hope.

Obviously, the legislation was enacted at the time with the best of intentions to try to deal with all of the results of the directions of the European Court of Justice. It was trying to address some of the issues involved. Mental health issues had to be involved and, in those circumstances, suicide was the most controversial aspect of the legislation, as the Deputy knows. I remember being on radio at one stage when there was a suggestion there should be 12 professionals involved. One of my children says it was a relatively proud moment to see my name on an Evening Herald poster on Pearse Street. It read: "Psychiatrist calls this idea a joke." I believed originally that the figure of 12 was a joke. The number was eventually reduced to three. All along I said there were simply not enough people available to do the work. I questioned how it would work and how it would be appropriate.

There is an acknowledgement that there are not enough psychiatrists in the country. Of course, there are psychiatrists. The three Dublin maternity hospitals have part-time psychiatrists. The major unit in Cork has a liaison psychiatrist who does a lot of work in this area. Throughout the country, however, there are very few. The requirement is that a psychiatrist must have treated a woman with mental health problems in pregnancy to be allowed to do this work. He or she has to be a consultant and to have treated a woman. That is the pragmatism of the legislation based on the problem of having enough people. Of course, there are not enough people available with the required training. A requirement was included afterwards that they be trained. One of the key issues is the nature of the training provided. There is none working in maternity hospitals. I might see a woman who wishes to terminate a pregnancy but who will have no idea of gestation or the difference between an emergency caesarean section at 24 weeks and the scar that will be on her body and a different procedure altogether if she waits a few more weeks. She will have no idea of various things. Equally, the assessing doctor will not either. The amount of experience and time it takes to deal with that issue is considerable. There is simply not enough training provided and not enough people used to doing this work. For all of the theoretical training, it is actually a matter of practice. I learn every day from the patients I am seeing. That is how we learn. Unequivocally, the system really does not work. Since it is so clumsy, the vast majority of women will come nowhere near us, appropriately so. It is just an unnecessary and unhelpful procedure. Therefore, women have to travel.

I do not have a breakdown of the very small number of women who find themseles in the circumstances to which the Deputy referred. Some of the cases that were very much highlighted have involved younger people and at least one refugee. I have not seen a breakdown of the numbers involved simply because I have not been involved.

Are doctors obliged to do this work?

Dr. Anthony McCarthy

No. Everybody can opt out if he or she so wishes.

A number of doctors have opted out because they felt they did not have the qualifications or experience or simply did not want to do it. There are real difficulties in finding a second psychiatrist, or two psychiatrists if the first psychiatrist does not want to certify. It is a real problem.

I have one very practical question. Can Professor McCarthy treat those aged under 18 years who are pregnant? Is there a distinction between child and adolescent psychiatry in that situation?

Dr. Anthony McCarthy

Pragmatically, if they are in Holles Street and expecting a baby I am not worried what age they are. If there was a case of termination, I would want a child and adolescent psychiatrist to come in.

I was struck by the humanity of Professor McCarthy's presentation and the fact he clearly understands and listens to individual women. He said that over the past 21 years more than 500 women attended the clinic each year. That goes back quite a long way. Would societal changes and attitudes to abortion have affected how women can talk about it? Has it changed how they feel about asking for or considering a termination? We know from opinion polls that attitudes have changed. A few of us here campaigned back in 1983 and we have seen a difference in public attitudes. Would that be reflected in Professor McCarthy's experience?

Dr. Anthony McCarthy

In my initial years after I came back from the UK I saw women who may not have told their obstetricians they had had terminations. They would come into the hospital and say they had one child or no children. On the second or third time I would see them, they would then tell me about a termination they had. Now, I am much more likely to hear such information at the very beginning. Of course there are changes. When I first came back, women with fatal foetal abnormalities got no information and got no support from my obstetric colleagues. Now there is a completely different culture and attitude towards that.

Has that improved the ability of women to deal with mental health situations?

Dr. Anthony McCarthy

I am always aware of the difference between giving an opinion and giving research evidence. As a human being, how can it not be better for someone to have a compassionate and supportive experience, and not feel judged in a hospital and that they cannot talk about something? There has been no formal published research on that, however.

In his contribution, Professor McCarthy referred to mental health outcomes after induced abortion and research evidence in the area. He pointed out that there is no significant research in Ireland. He gave the caveat that the advice he would give is that any research be looked at in a critical, informed and objective manner. He then spoke about the review of the mental health outcomes of induced abortions from the Academy of Medical Royal Colleges in the UK. He went through the key findings. I want to focus on the last finding.

There is a vote in the Dáil. I am hesitant to suspend, but we will have to because there are still a number of questions. I ask people to come straight back.

I can finish my question. We have eight minutes.

That is a matter for yourself.

Professor McCarthy said that the findings showed that an unwanted pregnancy was associated with increased risk to mental health, but the rates of mental health problems in unwanted pregnancies were the same after termination or whether a woman gave birth. I presume the research was carried out in countries with very liberal regimes. We heard evidence today that Ireland, Andorra and, I understand, Malta are the only countries in the vicinity which have very restrictive regimes.

Professor McCarthy, quoting women's personal experiences, said women who were exposed to strongly negative attitudes towards abortion in general were likely to have worse outcomes. My question may be unfair, but I will ask it. Would it be fair to say a very restrictive abortion regime, where there are constitutional provisions almost preventing women from having choice, would portray a very negative attitude towards women who wish to choose whether to have a termination?

Would it be fair to say that in very restrictive countries where abortion is almost impossible to obtain that would have a more detrimental effect on a woman's mental health if she then chose to have an abortion? If somebody had to travel or obtained pills on the Internet and had an abortion, would a restrictive regime be a factor in somebody's mental health?

Dr. Anthony McCarthy

Should I not answer the question until after the vote?

You can answer. Deputy O'Brien is a cool customer because he is not a bit worried. He will probably leg it. If he would rather the answer after the vote, it will give Professor McCarthy a chance to think about the response. We have to come back anyway.

Sitting suspended at 7.35 p.m. and resumed at 7.55 p.m.

We are in public session.

Finding (d) in Dr. McCarthy's presentation states "... women who were exposed to strongly negative attitudes towards abortion in general and to her personal experience, were likely to have worse outcomes". What could Dr. McCarthy extrapolate from that? In a country with a very restrictive abortion regime and very negative attitudes to women, for instance we criminalise women who have terminations, could he say whether the outcomes for women who go and obtain a termination are likely to be worse?

Dr. Anthony McCarthy

Again there is no professional evidence on the basis of professional research.

Based on Dr. McCarthy's experience -----

Dr. Anthony McCarthy

In general because of how we are as a society and have been for such a long time, people are not really thinking about that issue. I would not want to generalise, but it is for the individual person and whether she is really thinking in that way. What is really likely to matter is the views of those who are close to them or if there was some really publicly severe opinion. What comes out in research is that if her partner or a family member is really critical of them, that can be very difficult. If there is an argument, and sometimes I will witness an argument and a lot of conflict from a parent or from a partner, that is likely to add to the emotional distress that is involved. This research has never been conducted in Ireland, but we have American research looking at those going to abortion clinics in the US, where there is very public protest with people outside these clinics protesting and trying to stop abortions. For the person who is desperate or wants a termination, that sort of protest will not help them, or help their mental health. We know that if women have a mental health problem as a result of that experience, even in any future pregnancy, that mental health issue may become relevant again.

My follow-up question arises from Dr. McCarthy's public comments during the Protection of Life During Pregnancy Bill. One of his comments was why would any woman want to put herself through the process of having to go before a panel and almost have their mental health questioned. If we were to get to a position where we had a more liberal regime for terminations, where mental health was one of the grounds for it, I presume that analysis would stand no matter whether we had terminations in all circumstances. If somebody had to go before a panel of psychiatrists and almost prove that she had mental health issues, does it make a difference whether it is a very restrictive or a very relaxed liberal regime? I do not know how one would deal with having to put a woman through a process that is obviously going to be distressing for her. From the evidence we have heard today, would it be correct to presume that one of the ways one would deal with it is by on-request terminations up to a certain period? What would Dr. McCarthy's opinion be in terms of women's mental health? I presume Dr. McCarthy would say that it would never be good to have a woman almost have to prove her mental health status before she could access a termination, regardless of whether the regime is very restrictive or very liberal.

Dr. Anthony McCarthy

Irrespective of the issue of termination, I am unsure of how someone attending a psychiatrist could prove a negative or how the psychiatrist could determine it. When someone comes to see me or any psychiatrist, the first and most important element will be the relationship in the room. Can that person talk to me? Does she feel heard and listened to? That is the key starting point.

I attended a lecture some years ago given by Professor Aidan Halligan, who was an Irish paediatrician and the deputy head of the NHS in England. Speaking about medicine, surgery or any specialty, he said that the first thing any patient attending any doctor wanted to know was whether the doctor cared. If the doctor cared, then it was likely that the patient would be heard. Even where there was a cardiac complaint, the patient would know that the doctor was listening. The doctor would take a proper history and hear the person's story. If a doctor is not interested, he or she will miss things and, often, the patient will not tell him or her things. This is particularly the case in mental health. For someone to tell me personal, difficult things about herself, her history, her feelings and her previous experiences requires a sense of trust. If that appointment is imposed on her or I approach the matter in some judgmental way or bring my personal attitudes or history to it in either direction, it will be a failure of an appointment. Insisting that a woman go through a particular process where she must see a series of psychiatrists, or even just one, when she is clear on the situation in her own mind will be a waste of an appointment and abusive of her and she will be unlikely to talk about what matters because she is being forced into a situation that is not helpful. It would waste her time and my time and be damaging.

Could it have a more negative impact on her?

Dr. Anthony McCarthy

Of course.

I thank Dr. McCarthy for his evidence. It has been most helpful. I apologise for missing some of it, but I had to speak in the Chamber. Since some of my questions may have been answered, I will try to move through them quickly.

What percentage of women suffer from perinatal mental health issues during or post pregnancy? Is there any indication of that figure?

Dr. Anthony McCarthy

The terms "mental health problems" and "mental illness" are broad. In general, 11% of women get what is called postnatal depression. It is not a thing, but a label to highlight that after the birth of the baby is an extremely vulnerable time for a woman's mental health. It is a peak time for many reasons. I could spend an hour telling the Deputy about why it is such a poignant and vulnerable time for women with mental health problems.

According to some research, if women are asked to fill in a questionnaire during pregnancy, a higher percentage, perhaps 20%, will say that they are struggling. The most important message is that there is no decrease in mental health difficulties during pregnancy. In general, between 5% and 7% of women will have a significant mental health problem at that time. That does not lessen or increase overall. It may get much worse for an individual woman but much better for another. After the birth of the baby, the figure increases to approximately 11%. They have what is called postnatal depression, but for 3.5%, it is a serious problem.

How many perinatal psychiatrists are there in Ireland?

Dr. Anthony McCarthy

There is a little bit of me in Holles Street, a little bit of one of my colleagues in the Rotunda and a little bit of another colleague in the Coombe employed specifically in that role. There is none outside of Dublin. Professor O'Keane, who works in Tallaght hospital, addressed the committee. She has a long history of having worked in perinatal psychiatry, but she does not do that anymore. She is not working in a maternity hospital.

Outside of Dublin, there are no specialists and hardly any psychiatric input in some maternity hospitals except where, for example, a very small number of women become acutely psychotic or unwell. As to seeing women during pregnancy for assessments or afterwards in general, however, there is almost nothing outside of Dublin in terms of specialists.

Effectively, there are three part-time perinatal psychiatrists in Dublin and none outside. Is it fair to say that there is no designated mother and baby unit for mothers suffering from mental health problems?

Dr. Anthony McCarthy

Correct. I hope that my business managers are listening. It is to be hoped I will be a full-time psychiatrist in Holles Street in the near future. There are plans under the national perinatal strategy for mother and baby units, with one in St. Vincent's hospital when the National Maternity Hospital moves to that site. It would be for the whole of the city. As the committee knows, however, that move is some way off. Currently, there is no mother and baby unit in the country.

My next question is on perinatal mental health in general. What is the impact of having only a limited service?

Dr. Anthony McCarthy

One of the most important points about perinatal mental health services in general is that they are preventative. We are trying to prevent mental health problems in the mother or treat them early. In this way, ongoing bonding issues, attachment issues and mental health problems for the children are prevented. If we do not intervene, then the mother is badly depressed or anxious and not getting help, which can have a negative effect on children. That would perpetuate problems through the generations.

Would it be fair to say that the lack of extensive perinatal mental health care is putting women at risk?

Dr. Anthony McCarthy

Of course.

What kinds of mental health problems arise in pregnancy? What are the associated risks for the mother and the unborn?

Dr. Anthony McCarthy

For the mother, there is a panoply of issues. She may have had a major mental health problem previously, for example, schizophrenia, bipolar illness, anorexia nervosa, obsessive compulsive disorder, OCD, anxiety, depression, etc. For others, something new might emerge during pregnancy, for example, anxiety or depression. It could be any mental health difficulty. Some women will start drinking in pregnancy. Some will cope in unhealthy ways. For example, I have had patients tell me that they stopped taking their antidepressants because they were fearful of damaging their babies, but because they could not sleep at night, they were drinking four glasses of wine. Women who may have controlled their eating disorders suddenly become pregnant. The challenges to their bodies, such as the challenge of having something inside them, can trigger a relapse of a serious problem. Women who have managed or controlled their obsessive concerns may become completely obsessed and suffer a relapse of OCD during pregnancy that affects their anxiety and checking behaviour, perhaps because of reducing their medication or the responsibility of something being inside them. They are checking movements multiple times. They cannot sleep at night because they are double-checking, triple-checking and worrying about it. Maybe they have had a foetal loss before and cannot relax during pregnancy because of that. Maybe they are depressed. There are a range of issues.

What is the appropriate level of availability of mental health care for pregnant women in maternity hospitals? What should the management protocols be?

Dr. Anthony McCarthy

The Deputy should see the perinatal mental health strategy, which is about to be published by the HSE. I could be here all day discussing this. It will be attached to the national maternity strategy. If its recommendations come true, we will have mother and baby units around the country. We will have psychiatric services, not just involving psychiatrists, but also psychologists, social workers and occupational therapists. We will have teams in maternity hospitals, which would be good.

Is an independent analysis of the mental health outcomes of terminations necessary for Ireland?

Dr. Anthony McCarthy

It is unavailable at the moment. Terminations are not happening in Ireland, so how could one conduct research?

I wish to ask a brief question about a matter on which Deputy Browne and Dr. McCarthy touched, namely, patients currently in psychiatric services. I am unsure as to when they would attend. If they anticipate a pregnancy, would they have access to perinatal psychiatry at that stage to plan the medication aspect? It is a major concern for some women who have an ongoing mental illness. How is that managed? At what point do they move over to perinatal psychiatry? Do they need to be pregnant? What is involved in the planning? I would be interested in Dr. McCarthy's comments. For people with existing conditions, for example, bipolar illness, which is manageable in many cases, or anxiety about reducing or going off their medications during pregnancy can cause their illnesses to return, etc.

Dr. Anthony McCarthy

Any doctor seeing any woman of child-bearing age, no matter what her medical or psychiatric condition, should keep in mind that she could become pregnant.

Therefore, when prescribing, for example, a broad pressure, anti-asthmatic or epilepsy tablet, the doctor should be aware of that information. In the mental health area, particularly in complex medical regimes and specifically when there are complicating obstetric issues, women very often want to get specialists' advice. Some of my colleagues will sometimes want me to give specialist advice. To answer the Chairman's question, we see a small number of women before pregnancy specifically to provide this advice. Some women may already have obtained this information when they became pregnant by googling it or looking it up on a website. They may be perfectly happy with the local services available and may not feel a need to see me. Others will definitely want to see me, particularly those who have a bipolar illness and are on lithium. These women need very careful change monitoring. The change dynamics of pregnancy and the change in renal function - all sorts of issue in pregnancy - make the situation much more complicated. It is very much individual to the woman who will make up her mind, with the advice of her doctor, etc., on whether she should come to see us.

I thank Dr. McCarthy for his attendance.