Psychiatry of pregnancy


A perinatal psychiatrist speaks about the real life issues behind the abortion legislation debate, writes RONAN MCGREEVY

This coming year is likely to be dominated politically and socially by the abortion debate.

The battle lines were drawn long ago as the Government seeks to legislate to allow abortion in certain restricted circumstances. Most people are wearily familiar with the arguments ventured by the pro and anti-abortion sides.

The issue of suicide will be a particularly difficult one for the Government to resolve in legislation.

The expert group which advised the Government found that two psychiatrists and an obstetrician should assess whether or not a woman’s claim to be suicidal should be grounds for an abortion.

There are few experts in this notoriously difficult field. Ireland has only three perinatal psychiatrists for the whole State.

Perinatal psychiatrists

One of them is Dr Anthony McCarthy who works in the National Maternity Hospital in Holles Street and is also president of the Irish College of Psychiatry.

He treats an average of 590 patients in a hospital where there are 9,500 births every year. That amounts to about one pregnant woman in 20 who sees a psychiatrist.

Dr McCarthy says the absence of perinatal psychiatrists in every maternity hospital is a “scandal”, but that is a story for another day. He is understandably reluctant to give any hostages to fortune to either the pro-life or pro-choice sides, but simply to inform the “middle ground” as he put it.

For that reason he declines to comment on what legislation is needed for the X case judgment or whether or not he would become one of the psychiatrists who would sit in judgment on a woman who is threatening to take her own life.

In his professional life, Dr McCarthy has come across pregnant women who have died by suicide and women who have threatened to take their own lives.

He says pregnant women are no more likely to have mental health difficulties in pregnancy than the general population.

Some might find this surprising given the stresses, physical and emotional, which are well known in pregnancy.

There is a “myth”, he says, that women have fewer mental health problems in pregnancy and that can lead to post-natal depression afterwards.

Neither is it true, he says, as sometimes claimed, that no woman would kill themselves in pregnancy nor want to kill themselves in pregnancy.

He says suicide in pregnancy is “rare”. How rare? Nobody knows exactly because suicide is often under-reported.

He has come across pregnant women who have threatened to take their own lives, citing the example of one woman in particular who the current proposed changes in legislation “won’t help in any way”.

Profoundly distressed

He explains: “This was someone with a pregnancy where the foetus was incompatible with life. She is actually booked to have a termination of pregnancy in the UK, but presents saying ‘I will kill myself unless I can have it now’.

“This woman was profoundly distressed but she wanted to get rid of the feeling now, but actually she is going to have the termination of the pregnancy in a few days’ time anyway.

“My assessment very clearly was that ‘as of today she was not going to kill herself’. In fact she has a clear plan to go to England in a few days’ time and she wanted to live because she wants to look after her other children.”

He says such situations are rare because the “vast majority” of women who are so distressed that they want to go to Britain for abortion will do so without consulting a psychiatrist.

Dr McCarthy believes introducing legislation will not change that fact because a woman who is in that level of distress will not wait for the judgment of two psychiatrists and an obstetrician before going to Britain for an abortion.

“The only circumstances in the short term where this is going to present is in the X case where somebody is in the care of the State and therefore cannot travel freely. Those, again, will be rare,” he explains.

“The only other ones I can see coming would be those rare cases I see in an intensive care unit who are pregnant and they have taken a large overdose to kill themselves or harm themselves in other ways. They are very rare and will remain rare.”

Proper assessment

Dr McCarthy says that the important thing is that if legislation is brought in for suicide, that the women involved are properly assessed in a professional manner.

Those professionals who do not want to make the judgment call for ethical reasons should be allowed to opt out, he believes.

“What is very important is that if somebody is really distressed or in a difficult situation, that there are appropriately trained and experienced professionals who will make the best judgments they possibly can in that situation,” he adds.

He is dismissive of those who think even trained psychiatrists will be prey to manipulative women who will feign a threat of suicide to get an abortion.

Dr McCarthy points out that psychiatrists regularly see people who threaten to kill themselves if a certain course of action is not taken.

“We assess people regularly in all sorts of situations who are very distressed. We see people trying to manipulate us. We see this all the time. We see people telling us they are psychotic because they are trying to avoid a criminal trial. We are almost represented as being naive in that way.

“Does that make our job easy? No. Does it make our job extraordinarily fascinating and privileged to be in these situations. Yes.”

What if a psychiatrist makes a judgment if a woman threatens to kill herself, is refused an abortion and carries out the threat? He says psychiatrists will be indemnified in the usual way.

“We don’t get it right all the time. We are not perfect at it, but we’re very good at assessing people. We’re very good at recognising whether this is a mental illness, whether it is stress, whether somebody really wants to kill themselves, we have a lot of experience of that.

“Of course in that work we are indemnified. Doctors all the time take decisions in which we use the best professional standards, the best professional judgment and sometimes we get it wrong.”