Health Care Issues Arising from the Citizens' Assembly Recommendations: Masters of the National Maternity Hospital, Holles Street and the Rotunda Hospital

I welcome the viewers who may be watching on the Oireachtas television channel.

I want to make a brief request before I introduce the two delegates who are in attendance for this part of the meeting. The technicians have asked me to remind members to ensure their mobile phones do not go off. Apparently, there has been some interference and, according to RTE, much of the footage is not usable. It is really important for those speaking to keep their mobiles turned off. They should be turned off at all times.

On behalf of the committee, I extend a warm welcome to Dr. Rhona Mahony, master of the National Maternity Hospital, Holles Street, and Professor Fergal Malone, master of the Rotunda Hospital. Professor Malone will also represent the Royal College of Surgeons in Ireland as chairman of its department of obstetrics and gynaecology. Dr. Mahony and Professor Malone will address health care issues arising from the recommendations made by the Citizens' Assembly. I will not repeat what I said earlier about the provisions of the Defamation Act 2009. As they have both been here before, I am sure they are aware of the issues surrounding privilege, etc. Therefore, I will not repeat what I said earlier, unless they wish me to do so. I ask Professor Malone to make his presentation.

Professor Fergal Malone

I am the master of the Rotunda Hospital in Dublin and chairman of the Royal College of Surgeons in Ireland's department of obstetrics and gynaecology. I am a practising consultant obstetrician and a sub-specialist in maternal-foetal medicine. My particular area of expertise is prenatal diagnosis and the treatment of foetal abnormalities. The Rotunda Hospital is the largest provider of prenatal screening and diagnostic services in the State. Patients are referred to the hospital from all other maternity hospitals in the country. Therefore, I may be in a position to assist the committee in providing a factual context in the prenatal management of foetal abnormalities and considering the potential options for change.

I want to clarify that I am not here as an advocate for either a pro-choice or pro-life agenda. As a practising specialist, I understand it is absolutely crucial that patients trust their doctors to be completely objective in their professional medical advice and that they are not perceived in any way to have a political agenda. For this reason, I have always been cautious to keep my personal views out of the public realm. I am here to answer questions of a factual nature that the committee may have on foetal abnormalities and to discuss potential options for change in this area.

In the interests of brevity, I will not provide an overview of foetal abnormalities or prenatal diagnosis in Ireland. In addition, I will keep my descriptions of the care pathways followed by patients in this situation as short as possible. However, these matters are covered in detail in the written position paper I provided for the committee.

Currently, when a patient at the Rotunda Hospital is given a prenatal diagnosis of a fatal foetal abnormality, all options for management are discussed in a non-judgmental manner. The specific diagnosis is explained, together with what exactly is meant by the term "fatal". It includes quoting statistics for the chances of survival to birth and thereafter. There are two options for pregnancy management, the first of which is to continue with the pregnancy and provide perinatal hospice care. This care journey involves regular support from a multidisciplinary team. When the mother delivers, the parents generally hold their baby until such time as he or she passes away. This care journey is very well organised at the Rotunda Hospital and works in a tremendously supportive manner for families in terribly tragic situations.

The alternative option for pregnancy management in this situation is not to continue with the pregnancy, which means undergoing a pregnancy termination. This involves travelling outside the jurisdiction, most often to the United Kingdom. Patients who select this course of action are supported to the extent that is permissible by our legislation. We do not make direct referrals for a pregnancy termination, nor do we advocate for one management option over another. Parents must make their own appointments and travel arrangements. This particular journey is clearly associated with significant additional challenges for patients, including travelling for health care to an unfamiliar city and without family support. There is a significant financial cost of, typically, €800 to €1,500, not including travel costs. Limited autopsy or genetic testing is performed, as the cost of such testing must be paid for separately by the parents. In addition, there is significant distress for parents associated with leaving their baby's remains in a foreign country. In 2016, 55 patients from the Rotunda Hospital travelled to the United Kingdom to undergo a pregnancy termination following a prenatal diagnosis of foetal abnormalities.

The current legislative status of termination of pregnancy in Ireland poses significant practical challenges for obstetricians when faced with a prenatal diagnosis of fatal or complex foetal abnormalities. They include an inability to directly refer patients for care. The Regulation of Information (Services Outside the State for Termination of Pregnancies) Act 1995 prohibits our staff from directly making an appointment for a mother at a hospital outside the jurisdiction. We cannot contact staff in such hospitals directly on behalf of a particular patient but must rely instead on patients relaying potentially complex medical information.

Another challenge is the inability to access care in a timely manner. Recently we have been faced with a number of patients with fatal or complex foetal abnormalities who were unable to secure a timely appointment with a centre in the United Kingdom for a pregnancy termination because that centre had been too busy.

Another challenge is the lack of continuity of care associated with travelling to another jurisdiction. There is a distinct lack of fairness in that patients with complex foetal abnormalities who chose to continue with their pregnancy have prompt access to continuous care within a single health care team, while those who choose not to continue with their pregnancy are forced to endure split care across two jurisdictions, completely undermining the ability to provide for continuity of care. One of the main concerns in splitting care across two jurisdictions is the potential risks to the mother's physical health when travelling. Risks associated with pregnancy termination include infection and haemorrhage which has, tragically, already resulted in the death of one of our patients while travelling to the United Kingdom.

Another challenge is the threat of imprisonment for staff. As prescribed under section 22 of the Protection of Life During Pregnancy Act 2013, a term of imprisonment of up to 14 years may be applied if a doctor is convicted for participation in a procedure to "intentionally destroy unborn human life". There is a lack of clarity among some doctors on whether they may have a vulnerability to such a conviction if they are involved in any way in the management of a patient who has a pregnancy termination in another jurisdiction.

Given these practical challenges facing obstetricians and maternity hospitals in Ireland, I suggest the committee might consider supporting the decriminalisation of pregnancy termination in the setting of foetal abnormalities. Obstetricians and maternity hospitals in Ireland should be able to provide complete health care services for their patients without the threat of a criminal conviction. When faced with the practical reality of caring for mothers with complex foetal abnormalities, it is difficult to justify retaining a threat of criminal conviction for doctors or hospitals providing appropriate health care. Obstetricians and maternity hospitals in Ireland should be able to provide for a legal termination of pregnancy in the setting of fatal or complex foetal abnormalities if a patient chooses to follow that course of action. This would allow both pathways of care to be provided equally to all patients when faced with the traumatic situation of a prenatal diagnosis of complex foetal abnormalities.

With any proposed legislative change, it would not be appropriate to provide a list of specific foetal diagnoses that should be considered "eligible" for a pregnancy termination. Lists of foetal diagnoses are not static over time, just as any list of "eligible" diagnoses today would likely to be outdated in a number of years. Similarly, combinations of foetal abnormalities are commonly seen such that while, individually, a particular abnormality might not be considered "lethal", in combination with multiple complex abnormalities, the overall prognosis would effectively be fatal. It is recommended instead that the individuals best placed to make such a decision are the patient and her doctor, without the direct involvement of external agencies.

We do not consider it appropriate to specify a precise gestational age limit in weeks beyond which a pregnancy termination would be illegal. This is because the definition of foetal viability is not precise and is likely to change. Additionally, foetal size and foetal health are independent predictors of foetal viability, separate from defining viability based solely on gestational age in weeks. Again, it is recommended that the individuals best placed to make such a decision are the patient and her doctor, without an arbitrary legal cut-off.

I endorse the ancillary recommendations of the Citizens' Assembly which call for equal access for all patients to early pregnancy scanning and testing, improved counselling and support services for patients and detailed consideration of how a pregnancy termination should be resourced. Maternity services in Ireland remain significantly under-resourced. If we are to take on board the provision of pregnancy termination services, this will require a significant improvement in resources, both in terms of personnel and physical infrastructure.

I hope my observations, together with the more complete position given to the committee yesterday on the current status of the diagnosis of foetal abnormalities, are of assistance to the committee. I hope, too, that my observations on the practical challenges and options for change will be informative for the committee's future deliberations.

I thank Professor Malone. I invite Dr. Mahony to make her opening statement.

Dr. Rhona Mahony

I thank the joint committee for giving me the opportunity to come before it. I hope my contribution will be helpful in its deliberations.

I am the master of the National Maternity Hospital which is one of Europe's largest maternity hospitals and in which 9,000 babies are delivered every year. It is a major Irish tertiary referral centre which provides advanced obstetric, neonatal and gynaecological care. I am a specialist in maternal and foetal medicine and an honorary clinical professor with the Royal College of Surgeons in Ireland. My submission is based on my clinical experience as both an obstetrician and a master practising in the Republic of Ireland under the terms of the Protection of Life During Pregnancy Act 2013 and Article 40.3.3° of the Constitution, commonly referred to as the eighth amendment. These legal instruments govern the circumstances in which a termination of pregnancy can be lawfully performed in this country.

Termination of pregnancy is defined as the intentional procurement of a miscarriage. In other words, it occurs when a pregnancy is interrupted prior to foetal viability and neonatal intensive care is not provided. At present, 24 weeks of completed gestation represents the threshold of viability, whereby the provision of sophisticated neonatal intensive care is associated with approximately a 50% survival rate of the foetus. This is not an absolute cut-off point and some babies will survive at 23 weeks, while others will not be viable at 25 owing to complications of extreme prematurity. When a baby is delivered, in whom viability has been reached and for whom intensive care has been provided, we refer to this as a delivery, not a termination of pregnancy.

The subject of termination of pregnancy is deeply complex and, not surprisingly, it provokes strong views and many differences of opinion. We know approximately 3,000 women travel to the UK every year from this country to obtain termination of pregnancy. Our Constitution protects women travelling abroad for termination of pregnancy in circumstances that would be a criminal offence in their own country. In effect, this means that women in Ireland have similar access to termination of pregnancy as women in the UK, with the exception of children and women of limited means who do not have the ability to travel. It is impossible not to be affected by the personal testaments of individual women and their partners and, although every case is unique, it is evident that with the current position in Ireland, women will continue to travel to the UK or access unknown medication from potentially unregulated sources using the Internet with all the attendant clinical risk.

Somewhere in the midst of public opinion is the need to ensure that women in Ireland have access to sound clinical care, and I would like to address the following clinical issues. In Ireland, a woman qualifies for a termination of pregnancy if there is a real and substantial risk to her life that may be removed only by termination of pregnancy. The process that determines this qualification is cumbersome and complicated, and despite the fact that it relies on clinical judgment delivered in good faith to save a woman's life, it is framed in a criminal context. An error in clinical judgement is potentially punishable by a custodial sentence of 14 years for both the mother and her clinician in the event that an identified risk is deemed not substantial enough. Equally, waiting for a woman to be sufficiently ill in order that she is perceived to be at risk of dying is potentially dangerous. It assumes we can accurately predict the risk of dying. Haemorrhage, infection, heart disease, liver disease and a host of other disorders can make one very ill but they can also kill a person. It is not always possible to predict clinical course with precision. In medicine we deal with probability informed by available clinical evidence and experience.

In women with underlying morbidity, such as cystic fibrosis, portal hypertension, corrected congenital heart disease, renal disease and other conditions, the additional physiological burden of pregnancy can create significant maternal risk. The question arises as to how a substantial risk of mortality is defined. As I have asked, is it a 10% risk of death, an 80% risk of death or a 50% risk of death? A woman would also have a view as to what constitutes a substantial risk to her life and her view deserves consideration. It is not considered currently. This is real-life medicine. We frequently counsel patients about a range of risks and potential outcomes. We arrive at a decision with our patient's input, which we believe is in the best interest of our patient, but I cannot think of any other circumstances in medicine where risks to life are balanced in the shadow of a custodial sentence for both the clinician and the woman.

In my experience, one of the most challenging conditions we experience clinically is the development of chorioamnionitis prior to foetal viability. For example, if the waters around a baby break at around 14 weeks of gestation, there is really little chance the baby would be born alive and survive. We must wait until a woman develops infection or chorioamnionitis before we can intervene in the pregnancy. When the woman is at significant risk of developing such infection, we are tasked with ensuring we can terminate the pregnancy, which has become the source of the infection, before she becomes so ill that she dies.

In pregnancy we deal with two lives inextricably linked by a complex physiology. This is dealt with in the Constitution by a balance of rights. There is the equal right to life of the mother and the foetus. From a medical perspective, this provision creates difficulty in its presumption that the implications of a range of complex medical disorders can be reduced to a matter of individual right. If the legal world explores the balance of rights, the medical world explores the balance of risk. In a pregnancy complicated by serious disease, it is not a question of right but rather a question of risk. Once foetal viability is achieved, we have the option of delivering the baby and attempting to save both lives. We do this all the time in clinical practice and over 2% of babies in Ireland are born before term because of medical indication in the context of foetal or maternal disease. However, prior to foetal viability, we do not have the option of delivering a foetus because the foetus cannot survive, and if a pregnant mother dies, her baby dies too. Therefore, prior to foetal viability, this constitutional provision makes no clinical sense. Its presence facilitates a real possibility that clinical decision-making may be delayed or distorted as clinicians ponder the law rather than medicine.

Unfortunately, there is evidence of this. I will never forget the High Court case that dominated Christmas 2015 when somatic function was maintained in a dead woman so that her foetus could be incubated in what was described as a "macabre experiment". The woman in question was approximately 14 weeks' gestation when she died, which is weeks away from foetal viability. Her father had to apply to the High Court in order to switch off the machines and let his daughter be laid to rest with dignity. The overwhelming clinical judgment in the High Court attested that this foetus would not survive. It was a "futile exercise", according to the High Court, but it happened because of a medico-legal interpretation of the eighth amendment and it could happen again.

In addition to being an obstetrician, I am a specialist in foetal and maternal medicine. The National Maternity Hospital, NMH, is a large tertiary centre for foetal medicine and we are fortunate to have a large multidisciplinary team, including neonatal, midwifery, bereavement, radiology, paediatric, obstetric, genetic, social work and pathology experts to provide guidance and expertise required in the context of complex foetal anomaly. A care pathway has been developed that adopts a multidisciplinary approach to provide individualised care to families. We see women from all over Ireland and we know it is very difficult for families who have to travel long distances for care in the context of foetal anomaly. In 2016, 195 women with a foetal anomaly were referred to our hospital from units around the country.

The specialty of foetal medicine is increasing in complexity, and our ability to identify genetic and structural anomalies in the foetus in utero is increasing. New techniques include the ability to detect chromosomal abnormalities by testing free foetal DNA carried in a mother's bloodstream from as early as ten weeks of gestation. This is done using a simple but expensive maternal blood test. Micro-array technology allows us to examine the chromosomes and see genetic material more clearly and foetal imaging has improved, including enhanced ultrasound and, more recently, magnetic resonance imaging provided at NMH. Interestingly, a third of units in Ireland do not provide routine anomaly scanning, which is hard to justify in 2017. In 2016 at NMH, we identified 400 significant structural anomalies and more than 60 chromosomal anomalies. The diagnosis of a major foetal anomaly and particularly a foetal anomaly in which survival is unlikely after birth is a really difficult part of my job. I know when giving such devastating news that I change a family's life irrevocably. Counselling is always non-directive but includes the variety of options available in each individual case. Even where there is a strong likelihood a foetus will not survive, women wish to continue their pregnancy knowing what will be but they tell me that whether their baby survives for a minute, an hour, a day or a week, the time is of infinite importance. The foetal medicine team and multidisciplinary neonatal teams, in conjunction with our bereavement team, support parents in this context as best we can in each individual circumstance. We now have national standards of bereavement care that address anticipatory bereavement. Strategies include individualised care, memory-making, support and advice for family members, as well as bereavement counselling. Some people call this concept perinatal hospice care.

For some women the decision to continue with a pregnancy can be associated with increased maternal risk. For example, in a case of conjoined twins where separation is not possible because of organ sharing, there are significant technical difficulties in delivering the conjoined babies requiring high-risk caesarean surgery. In the context of a really severe lethal anomaly in which a baby is unlikely to survive, some women will not wish to continue their pregnancy. They will choose to navigate these tragic circumstances in different ways. I understand people will make different choices when faced with really difficult personal circumstances.

Sixty women attending our service travelled to the UK for termination of pregnancy in the context of foetal anomaly in 2016, and to date this year at Holles Street, 43 women have travelled in this context. The majority of women had pregnancies complicated by chromosomal or genetic anomaly, multiple anomalies, anencephaly and ventriculomegaly. UK data indicate that in 2015, 135 women travelled from Ireland to the UK in the context of foetal anomaly where they terminated their pregnancy under clause E, "substantial risk of physical or mental handicap as to be severely handicapped". Women who chose this option must travel to a different jurisdiction. The Constitution protects women who decide to travel but a termination in this country in this context would be a criminal offence.

As an obstetrician I can give limited practical support in this decision. This includes contact details of foetal medicine centres in the UK. We do not make direct referral for pregnancy termination and we certainly do not advocate for one management option over another. Parents must make their own appointments and make their own travel arrangements. Families must find this especially cruel. Parents also bear the cost of treatment in the UK, which can run to more than €1,000, including medical treatment, flights, accommodation, laboratory bills and the cost of bringing their baby's remains home.

In this context, parents frequently report feeling abandoned and the tragedy of their loss is exacerbated by the practical difficulties of bringing their baby home, navigating a different city and jurisdiction, being separated from their families at such a difficult time and the shame and stigma associated with travelling to England for a termination of pregnancy.

From a clinical perspective, care between two different jurisdictions is inevitably disjointed and clinical risk is increased. I am struck by the findings of the UN Human Rights Committee which on several occasions has found that the current criminalisation and restrictive abortion provision in Ireland today violate women's human rights, including the right to freedom from cruel, inhuman or degrading treatment, the right to privacy and the right to freedom from discrimination.

I have raised a number of difficult issues which I have encountered in my medical career. No law will ever adequately address the reality of the ethical dilemmas generated by human reproduction but we have to acknowledge the real risks that women face in clinically complicated pregnancies. I believe there are two main domains that need to be addressed from a clinical perspective. We must address the criminalisation of medical care in Ireland. At present a woman must have a substantial risk of dying before she can qualify for a termination of pregnancy to save her life. Failure to adhere to this is punishable by a 14-year custodial sentence for both the woman and her doctor. I believe this has the capacity to create clinical risk by distorting clinical decision-making.

In September 2017, the council of the Royal College of Obstetricians and Gynaecologists voted strongly in favour of supporting the removal of criminal sanctions associated with abortion in the UK. They said: "We believe that the procedure should be subject to regulatory and professional standards, in line with other medical procedures, rather than criminal sanctions." It is also very difficult that our Constitution protects women to travel in the context of a baby that has a foetal anomaly that is unlikely to survive and yet to terminate a pregnancy at home in this country in this context is a criminal offence.

Second, we must address access to safe clinical care. Women require safe health care and sound clinical decision-making in the context of pregnancy complicated by severe maternal disease. A women herself should have an input into her care management and both she and her doctor must have the flexibility to make sound clinical decisions in good faith. It should not be a requirement that she is dying prior to these decisions being made. Timely appropriate clinical decision-making in pregnancies associated with significant maternal risk will make women safer. Children require special consideration in relation to risk.

In the context of severe foetal abnormality, in terms of access, women are travelling to jurisdictions outside Ireland to access complex medical care. While doctors provide non-directive counselling and can provide information on termination of pregnancy, doctors cannot make appropriate clinical referral. Care delivered between jurisdictions raises all kinds of risk, including lack of continuity of care, inability to access timely care, incomplete evaluation and confirmation of prenatal diagnosis, and incomplete analysis of the implications for future pregnancies. Patients would much prefer to have the option to access this care at home close to their families and friends.

The presence of the eighth amendment in our Constitution creates unacceptable clinical risk and it should be removed.

I thank Dr. Mahony for her presentation. I will now move on to questions. Our first questioner is Deputy Catherine Murphy and she has eight minutes.

The witnesses are very welcome to the committee and I thank them for their papers and giving us the benefit of their expertise. My first question is for both witnesses. Dr. Mahony said that about one third of hospitals do not provide a certain type of screening. Is the eighth amendment any influencer on that or is that just related to how we deliver health care?

Dr. Rhona Mahony

I believe that is a resource issue but, in reality, there are two main opportunities for women to have prenatal screening. The first would be in the first trimester when chromosomal anomalies can be diagnosed using a maternal blood test, but that is very expensive. It costs about €350 and it is an opt-in test, so women who do not have the means to pay for that will not access that test.

Regarding the reference to one third of hospitals, I was referring to ultrasound scanning. It is a standard of care obstetrics in 2017 that women would have anomaly scanning. The primary reason for anomaly scanning is that if there is a difference or a challenge picked up for a baby, it is really important that we identify that in order that we can provide the best possible care to a mother and her baby. For example, if we diagnose that a baby has a congenital heart problem, we can connect the mum and the baby with the services that will be required after the baby's delivery with the surgeons and all the multidisciplinary care because we know that there is a problem. That is the most important reason for providing ultrasound scanning. It is to our shame that a third of units in this country do not provide routine anomaly scanning.

I totally agree with Dr. Mahony on that. In terms of the issue of criminalisation, I found myself, probably like others, faced with whether we supported legislation after not being able to amend it. I can understand why it would be incredibly difficult to work in that kind of an environment and make the judgment calls in real time. That legislation was around legislating for what is in the Constitution - the equal right to life.

I would like to move on and ask about the right to health, which is deemed by international human rights organisations as a right, but it is very difficult to see how the right to health can be provided for in the context of the eighth amendment. Dr. Mahony might speak a little on that and how she might differentiate between serious risk or risk, whether she should be differentiating, and whether that ought to be something that is very much down to the clinician and the woman involved.

Dr. Rhona Mahony

I really believe this is where clinicians and their patients need flexibility to look at the implications of health issues during pregnancy. Some women come into pregnancy with conditions of cystic fibrosis or portal hypertension and there may be a significant risk of that woman dying because of the additional physiological burden of pregnancy. Similarly, women can become ill during pregnancy and we need to interrupt the pregnancy prior to foetal viability. Once foetal viability is achieved, we can deliver a baby because of either maternal or foetal disease, and as I said, we do that all the time. A total of 2% of deliveries in this country occur early before term because a woman or baby is ill and we can deliver before term. It is prior to viability that the problem arises when we do not have the option of delivering a woman's baby. In those cases, we have to look at the risks to that woman and that is where clinicians need flexibility. I do not think it is appropriate that we somehow have to wait until a woman is at a substantial risk of dying because how does one define that? As I said, what is a substantial risk? Is it 5%, 10% or 50%? What of the woman's view? If I say to a women that she has a 10% chance of dying but I am okay with that, she might disagree with that and say: "Well, doctor, I am not okay with that." This is real-life medicine. We cannot predict the clinical course all the time with exact precision. We have clinical evidence, likelihoods and probabilities. Therefore, what clinicians and their patients require is flexibility.

I want to ask Professor Malone about the point he made about limitations, gestational limits, and that it is something that should be a clinical issue as opposed to something that is set down. He was talking in the context of foetal abnormalities, but does he believe that should be the approach generally or only in the context in which he was speaking?

Professor Fergal Malone

I was making my comments today in the context of foetal health and foetal abnormalities, because that is what we deal with at the Rotunda Hospital and in the maternity hospitals. As I pointed out in my paper, viability based on gestational age is just one aspect of viability. One could have a baby with severe growth restriction at 25 weeks who is 300 g and has no prospect of survival, yet one could have a 23-week foetus who is 600 g and has a prospect of survival. One could have a 25-week foetus with a very severe heart defect that has no prospect of survival if that foetus was born, yet a 23-week foetus that is completely healthy might have a chance of survival. To focus our definition of viability on some arbitrary gestational age week is just one piece of the equation. It is not possible to define viability in the total context of health. That is why one needs all the other pieces of information. The doctor together with the patient are the best placed to make that decision.

I thank Professor Malone for that response.

The Deputy can ask one further brief question.

On the issue of continuity of care, prior to the legislation I travelled to Liverpool and it was helpful meeting the team there. One of the questions one of the group asked was whether there was a difference between Irish women and women from the UK attending. This was in the context of Doctors for Choice in regard to foetal abnormalities. The response was that the one difference they could see was that Irish women felt that they would be judged, which in that kind of environment was an added pressure in addition to the travel, etc. In an earlier session, we heard about women sometimes not talking to their doctor and opting for online medication because they feel that they would be judged. In regard to the medical profession, is there a discussion on how, when women present they are handled non-judgmentally and for people to expect it to be non-judgmental?

Professor Fergal Malone

At present when patients come back to us after going to the United Kingdom, they are managed in a completely professional and non-judgmental way. We understand the terrible journey that they have made. One has to realise these are very much wanted pregnancies where everything was going along well and suddenly the rug was pulled out from under them, they were diagnosed with this major abnormality, and they found themselves on this journey to another country with a sense of shame and, as the Deputy points out, being judged. It is tremendously traumatic for them. We feel strongly that patients, when they return, get the complete care that they would have received had the procedure been performed here. We try to pick up the pieces as much as we can, given that the procedure happened elsewhere. We work closely with our colleagues in the United Kingdom. Our team generally have gone to visit the units in the United Kingdom. We try and demystify it as much as possible by telling our patients who they are likely to meet to try and make the terrible journey just that little bit easier, and help them when they come back, but it is tremendously difficult.

Dr. Rhona Mahony

It is so difficult to travel when one's pregnancy is complicated in a way that it is very unlikely one's baby is going to survive, or the baby is going to have a really severe challenge. It is really very difficult to have to go to a different country, to doctors in a hospital one does not know, to be away from one's family and to have that stigma of getting on the plane to access a termination of pregnancy, and to know that in one's own country it would actually be a criminal offence.

I thank the doctors. Deputy Durkan has approximately five minutes left from his previous time.

I thank the witnesses for coming before us and for their informative opening papers.

In regard to the determination of fatal foetal abnormalities, are there any particular situations that come to mind, given the previous history of medical conditions, where it might be possible to indicate to the potential mother that she could be in danger and how often have they occurred? In regard to the women who found themselves in the situation of having to travel overseas - Dr. Mahony mentioned 60 who so opted in the last year - how many in the same period opted not to travel with similar situations? In the event of there being a change in the legislation taking the criminalisation out of equation, might there be a reluctance on the part of some professionals to participate in terminations?

On the question raised by Deputy Catherine Murphy in regard to the threat to life arising from a health condition, have these doctors been able to identify particular health conditions that will eventually lead to a life-threatening situation, and one or two that come to mind straightaway?

Professor Fergal Malone

Specifically, on numbers of cases, I told the committee that in 2016, 55 women with foetal abnormalities from the Rotunda travelled to the United Kingdom for pregnancy termination. As regards women who decided not to travel, for example, Down's syndrome, in 2016, we had 26 cases in which we diagnosed prenatally Down's syndrome. Some 57% of patients chose to travel to the United Kingdom and 43% chose to stay and continue with their pregnancy. There were 24 cases of trisomy 18, known as Edwards' syndrome, a fatal foetal abnormality, diagnosed in 2016. Twelve chose to travel to the United Kingdom and 12 chose to continue on with their pregnancy. In general, it depends on each abnormality, approximately 50:50 is how it splits out. That reflects the balanced counselling that is done. It reflects the fact that when we make a diagnosis, we give patients the full facts as to what it means. They meet various support organisations, as needed, and they make their own individual family-based decision. Those were the numbers in 2016.

Deputy Durkan asked on fatal foetal abnormalities and how often maybe the mother was in danger. There are some conditions, such as trisomy 13, or Patau syndrome. Patau syndrome is strongly associated with severe preeclampsia and the foetal condition can actually make the mother sick. There is another condition called Mirror syndrome where the foetus gets heart failure called hydrops and that could have the same effect on the mother, and the mother goes into heart failure. There are definitely cases in which the foetal condition can have a tremendously negative effect directly on the mother.

The Deputy asked are we concerned that there may be reluctance on the part of some medical personnel to participate in procedures should there be a change in legislation. We have never had a survey done of doctors in Ireland to see where would they personally stand on this issue.

The issue of conscientious objection is a valid one and we would generally always accept that. In large hospitals, such as the Rotunda, the Coombe and the National Maternity Hospital, I would be confident that we would always have sufficient numbers of personnel available that, even if an individual doctor chose for personal reasons not to participate in a case, we would be able to provide care for the patient. I would perhaps be a little bit more concerned, if one were in some of the smaller hospitals where one had more limited personnel, would the conscientious objection clause prevent a patient accessing appropriate care. That remains to be seen.

Dr. Rhona Mahony

Similarly, in regard to fatal foetal abnormality and danger for women, there are the medical disorders, such as preeclampsia, as discussed, but there can also be significant surgical complication. I cited the example of a case of conjoined twins where, if this pregnancy goes to term and significant organs are shared, there is no prospect of survival for the conjoined twins but in order to deliver them, there is great technical difficulty and very complicated surgery which can create a high risk indeed for a patient.

In terms of travelling, we diagnose approximately 400 foetal anomalies a year in the National Maternity Hospital and approximately 60 women travel. A lot of women would choose not to travel. Among those 400, there will be anomalies that are less severe, for example, a number of heart issues, that are amenable to treatment and to surgery. That is why we work so hard to pick up an anomaly so that we can offer the best possible care to babies when they are born because that can really improve outcome.

Of the 60 women who travel, they tended to be chromosomal and genetic anomalies. They tended to be neural tube defects, cranial abnormalities and complex heart abnormalities. They tended to have abnormalities that were at the very severe end of the spectrum indeed.

In regard to criminalisation and reluctance of clinicians to participate, women should be very much reassured in the first instance that when it comes to a risk to a woman's life we will do all that we can to save her life.

That is normal obstetric practice. We will always endeavour to save a woman's life, and that is really important. There are underlying maternal conditions that do create a very high risk in pregnancy, for example, portal hypertension, very advanced cystic fibrosis where there is very reduced lung function, some congenital heart disease, some cancers and some very complex haematological disorders. There will be very rare disorders as well of which we have limited experience but there is no doubt that there are underlying maternal diseases, and when the physiological burden of pregnancy is added to them, it creates substantial risk for women.

Unless it is a clarification.

I will be a very good boy and be very quick. Why should a woman's life be artificially prolonged, for want of a different expression, to facilitate the development of a foetus? Would it not be obvious to most people regardless of the law that it was an abuse of the system? Why should it take place? How has this taken place?

In respect of a baby who dies prematurely before the normal gestational period, what is this thing we have come across from time to time where the woman has to wait until the normal gestational period has passed before the baby is born even when the baby has been dead for maybe six or seven weeks or two months? Does that still continue or has it been discontinued?

Will both witnesses address those questions as briefly as possible?

Professor Fergal Malone

Regarding the latter point about a foetus dying in the womb and a woman waiting to deliver that baby for many weeks, generally that does not happen now. Once a diagnosis of intrauterine demise is made, we would generally get on with the appropriate medical management of that fairly quickly.

Generally but not always.

Professor Fergal Malone

I will give the Deputy an example of when we might not do so. This would be when there was an intrauterine demise in the setting of a twin pregnancy. If there is another live foetus there, clearly, we do not want to endanger that foetus by delivering it early so that is why I cannot give the Deputy an "always" on that.

Does Dr. Mahony wish to address the other question?

Dr. Rhona Mahony

The first question.

It relates to prolonging the mother's life artificially to protect the life of an unborn baby.

Dr. Rhona Mahony

There are very limited-----

Dr. Rhona Mahony

As the Deputy can imagine, there are, thankfully, very limited case reports in this area. We might ask how it happened, but the point is more that it did happen. It happened in this country and it happened in 2014. It happened because of an interpretation of the eighth amendment under which doctors felt that there was an equal right to life of that foetus.

I thank Professor Malone and Dr. Mahony. In respect of that grotesque case, that is all one can say about it. It was utterly disgraceful and I hope to never to see it happening in this jurisdiction or anywhere else again.

In respect of fatal foetal abnormality or severe abnormality, one of the concerns often put out there is that there could be many misdiagnoses - that doctors are getting it wrong essentially. That is the fear that is put out there so will the witnesses address that concern? Will they elaborate on the impact on the parents and the mother of having to travel in those circumstances? Do they think it has a long-term severe impact on those individuals and how they feel afterwards? Dr. Mahony spoke about having to wait until the woman was at risk of death. Will she elaborate on that process? Who decides? How close to death does the woman have to be before we act? Who is making that call? I was shocked to hear Dr. Mahony say that the woman has no say in that process. How many people are involved in that process?

Professor Fergal Malone

Regarding getting the diagnosis wrong and terminations being performed on foot of an incorrect diagnosis, I do not believe that this happens in contemporary obstetric practice. Genetic diagnoses are black and white. Some people mistake screening tests for diagnostic tests. It is possible that a screening test that assesses a patient's risk for having a baby with Edwards' syndrome or trisomy 21 may say there is a high risk. That does not mean the foetus has the condition. We would never suggest that a woman travel or see a woman travelling for pregnancy termination for a risk of a condition. We would always recommend in 100% of cases that a patient would have a formal diagnostic test done such as amniocentesis or chorionic villus sampling, CVS, so that we do not get the diagnosis wrong. It does not happen in that situation. In terms of structural abnormalities diagnosed by an ultrasound, we are very careful in our counselling with parents as to the accuracy of what we see and the limitations of what we see. Commonly, I will say to a patient that there is an abnormality with the heart, or that there is a hole in the heart and the blood vessels are lined up in such a way but that is what it looks like to the best of our knowledge, or that there is an abnormality of the brain but I cannot tell the patient exactly what effect that will have on brain function. We always express the limitations of the diagnostic test. If it is 100% certain, we will say that. If it is just a set of findings and we do not know what it means, we will also say that so there is no question of people having pregnancy terminations for a wrong diagnosis.

It is very difficult to specify the impact on parents travelling because it would be very useful to have longer-term follow-up questionnaires and studies of depression scores and anxiety scores afterwards. My gut feeling is that there are significant long-term effects from the trauma of travelling. It is very hard to distinguish between how much of the subsequent anguish was due to the original diagnosis, which is understandable, and how much was added to it by the subsequent practical challenges. We do not have any data on that so I cannot give the Deputy a direct answer as to how often that happens. My gut feeling is that it is common.

Dr. Rhona Mahony

The risk of dying is covered in sections 7 and 8 of the Protection of Life During Pregnancy Act 2013. Section 7 covers the substantial risk to maternal life while section 8 covers emergencies. In the context of an emergency like a haemorrhage, a doctor can make a decision on his or her own and interrupt the pregnancy to save a woman's life. They do not need a second opinion but can go straight ahead. In respect of a substantial risk to life, it requires two doctors to come to that opinion, one must be an obstetrician, one can be another relevant practitioner and preferably a general practitioner would be involved as well in the decision-making. Again, it comes down to the determination of what is a substantial risk to life. We will have patients presenting who may have a disease like advanced cystic fibrosis or portal hypertension. They may not have planned to get pregnant but now they are. When the question arises, we are not quite sure what the clinical course will be. We know there are risks but is there really a risk of the woman dying or will she just become ill? How do we factor that in and what is our opinion? What is really required in these situations is the ability for the doctors and patients to look not just at the risk of dying but at the risk of a serious impact on a woman's health in order that they can make a sensible and timely decision. I believe that the definition of substantial risk to life can provide problems for doctors who are worried that if they make a wrong clinical decision, a custodial sentence of 14 years is hanging over both them and their patient.

I remind members that we are moving to the general questions where everyone will have six minutes. I ask members to ask questions rather than make statements. I do not mean to preach but it is very difficult for me to manage the time here. Our witnesses are giving their time to come here and we want to get as much information from them as we can. I do not like to interject with the witnesses when they are giving us information we need to get from them, so I ask members to be mindful of that when asking questions.

I welcome the witnesses. I note that, in his submission, Professor Malone advocates neither a pro-choice nor pro-life agenda but he wants very strongly to call for abortion to be made available where babies have a disability. I note that he stated very clearly that no specific disabilities should be excluded from that list. He called for the decriminalisation of abortion where babies have foetal abnormalities. At the top of page seven of his opening statement, he suggests that the committee should consider decriminalisation of pregnancy termination in a setting of foetal abnormality. This is a disability where the baby is necessarily likely to die. I think Professor Malone made his position very clear here today and what that actually would mean, and I note that he referred to having the facilities available in Ireland in order that patients can access care.

It is clear that what is meant by "care" is a procedure that would lead to the ending of a baby's life and I appreciate the honesty of the witness. Nevertheless, I find it very disturbing and I point out that families in very vulnerable positions place their trust in doctors. I note the witness referred to the sensitivity that doctors are obliged to have in dealing with families. I do not doubt he knows that. I know families which have found themselves in very vulnerable positions and any word from a doctor is treated with the utmost seriousness and can influence a decision. I find it disturbing that the witness refers to the abortion procedure as "care" as it is certainly not care.

Please ask questions.

Is it true that the witness is describing the abortion procedure as care? At what point is it decided that the baby is no longer the patient?

I have some questions for Dr. Mahony about abortion on health grounds. If abortion is introduced on health grounds, even very restricted health grounds, there is definitely no way back. It is not a case of not trusting women. I trust women and so does everybody with a concern in this regard. We must look at other countries, like the UK, where there are 200,000 abortions per year, mostly on health grounds. One can use any restrictive language in legislation but there is no way to stop abortion happening on more wide-ranging grounds. Will Dr. Mahony comment on abortions done on health grounds?

Professor Fergal Malone

In my paper I did not state there should be no exclusions for foetal abnormalities; it was the opposite. I said we should not have an inclusive list as the problem with such a list is that we cannot be that prescriptive. It is possible to have an abnormality, such as hypoplastic left heart syndrome, for example, which in itself is not necessarily fatal but is very severe. If it is combined with a foetus that has severe growth restriction and a major intracranial abnormality, the combination would create a case where there is no meaningful prospect for survival. That was my point about not having an inclusive list. I certainly do not hold the position, and I have not stated as much in our paper, that we do not exclude any abnormality. There are practical problems with trying to create an inclusive list. It cannot be done.

With regard to termination of pregnancy as an example of care, we look after our patients to the best of our abilities. Patients of all types and backgrounds come to see us for care. Of the patients faced with these tragic cases, many will decide to continue their pregnancy. I have given the committee figures on that. We support them every step of the way and help them in the most caring possible way. There is another group of patients for whom it is just not possible for them to continue with their pregnancy when they see the case as being futile. We are not allowed to care for them to the best of our ability now and we are forced to care for them in a split way. They go to the United Kingdom or elsewhere for a pregnancy termination, with the associated stigma, shame and physical risk. We have had a woman from Ireland die on her way back from a complication of the procedure after travelling to the United Kingdom for a pregnancy termination. We cannot care for these people who make that decision in the way we want to care for them. That is why I am here today to suggest we should be allowed care for all of our patients, irrespective of their personal, religious or moral background.

Dr. Rhona Mahony

I appreciate the Deputy's concerns about the health grounds factor. There is the question of what is health and what is dying. As I keep coming back to it, clinical courses are very difficult to predict with precision. An illness in a woman can very quickly kill her. It is our difficulty in exactly predicting a clinical course, so we should therefore err on the side of ensuring women are safe and appropriate and timely decisions can be made. It is not appropriate that a woman must be dying before she qualifies for a termination of pregnancy.

When we look at maternal deaths, a significant proportion are related to women with other diseases during pregnancy, like cystic fibrosis and bleeding disorders. We must acknowledge that when we consider risks to women. What is required is sound clinical judgment. There must be trust in society that doctors and women will come to make a good decision that will keep women safe.

In most cases of pregnancy women really want to be pregnant and I have seen women risk their lives in order to have a baby. It is not really the risk of dying that makes women suddenly want to terminate a pregnancy. These are often babies that are really wanted but the women become too ill or are at risk of dying. As clinicians, we are charged with getting complex clinical diagnoses right in what can be a very narrow therapeutic window.

I will bring the committee back to the example of ruptured membranes at 14 weeks. There is very little chance a baby in that scenario will survive but there is a significant risk for that woman that she will develop an infection called chorioamnionitis. This is where the pregnancy itself becomes the infection and the woman would be at a substantial risk of dying. The only way to treat the infection is to terminate the pregnancy and give an antibiotic. When we have a clinical suspicion of chorioamnionitis, we might not get microbiology results as confirmation for 48 hours and we must make a clinical decision. Therefore, doctors are concerned that if they intervene too early, it might not really be chorioamnionitis and they might have got it wrong. They might be at risk of a custodial sentence. They may wait too long. Women and young women in particular often decompensate very suddenly and can appear much better than they are. They can appear quite well and have very advanced infection. If they decompensate, the clinician would be in a position where he or she must conduct a termination of pregnancy in a woman who would be very ill. It can be a very narrow therapeutic window and doctors are charged with getting it right. Somewhere in society we must accept that women and their doctors will make responsible decisions there to protect life.

I thank Professor Malone and Dr. Mahony for their presentations today, which are very clear. It is important we get the clinical view and practice on the ground so as to under the concerns of the witnesses, particularly the question of what point clinicians should intervene to save the life of the mother and ensure she has no long-term health implications because of that wait and the legal fear influencing it. It is very important to have that clarification today.

Professor Malone mentioned a split care between the two jurisdictions in the case of fatal foetal abnormalities. Have the witnesses heard of any experience with aftercare with regard to abortion pills? I know there are legal implications around that as well, as Professor Malone alluded to in his opening statement when he spoke of a clinician's fear about being seen to treat people who have taken abortion pills when aftercare was required. Will the witnesses expand on the types of personnel and expertise needed in the event of abortion being available in Ireland under whatever circumstances?

Professor Fergal Malone

We have experience of aftercare following patients taking medication to bring on a pregnancy termination as patients present to us in the accident and emergency room of the Rotunda Hospital, for example, with bleeding or an incomplete procedure. There may be some placental tissue, for example, left inside. I assure committee members and patients at large that when patients present in such cases, they will never be judged and will always get absolute top-quality care immediately. There is no question of patients being quizzed as to what their motives were or adding to their difficulty. They will always get appropriate care. Unfortunately, we have significant experience of patients coming to the accident and emergency room having taken medication and perhaps not doing so in the appropriate way. The other problem, as I noted in my position paper, is that when one sources medication like that on the Internet, one would have absolutely no idea what is received. It can be a very challenging issue.

The Deputy asked about the personnel needed should there be legislative change such that pregnancy termination would occur in Ireland. In general, there is no significant difference I foresee in terms of skill set. Medical termination of pregnancy is very similar to what we do now when patients present at 12, 14 or 16 weeks with the unfortunate situation where a baby's heartbeat has stopped.

The same medical process occurs. Surgical pregnancy termination earlier in pregnancy, meaning at less than 14 weeks, is, technically, the same procedure we do at present when patients present with what is called a missed miscarriage. I do not foresee any significant difference in the need for qualifications of personnel. I do, however, foresee a significant increase in resources needed. Last year, 55 women went from the Rotunda to the UK for pregnancy termination for severe complex foetal abnormalities, which is one case a week. I am reasonably confident the Rotunda would be able to absorb that workload into our current situation. If many more patients who terminate for other reasons were to have those procedures performed in Ireland, there would be a significant resource implication for us. By "resources" I mean personnel numbers and a physical environment in which to care for patients such as these in an appropriate manner. The Rotunda is a wonderful place and a wonderful building, but it was built in 1757. We do not have much expansion room to care for those large numbers, so there would be a significant requirement of resources.

I call Deputy O'Reilly, who has six minutes.

I thank both of the witnesses for coming in. We appreciate how busy they are and we are very grateful for their time and expertise in this matter because we are politicians and they are the experts. It has been very informative so far. Professor Malone referred to the need to provide complete health care services for women. For the avoidance of any doubt, and I want to keep this brief, that includes the provision of access to abortion and the aftercare that goes with it. I am not trying to put words into Professor Malone's mouth, but I want to clear that up first.

Foetal anomaly scanning is very hit and miss, and this is something I have spoken about on numerous occasions. Dr. Mahony is nodding. It is unfortunate that a woman may find out very late in her pregnancy that the foetus has a fatal or lethal anomaly. Does having to travel on top of this add to the complications? Clearly, it will increase the stress, but does it add to the complications? Were the woman able to access abortion services here in Ireland it would considerably decrease the stress and, as Professor Malone outlined, the potential for physical harm, as happened in one very unfortunate case.

My final question relates to a reference in Professor Malone's evidence to post-termination autopsy and genetic testing. Will he speak to us briefly about how important this is and what we can potentially learn from it? Is that information completely unavailable because the procedure is carried out in another jurisdiction or is some of it available? I ask Professor Malone to tease out how it works.

Professor Fergal Malone

The Deputy is absolutely correct in her initial characterisation of my comments. When I call for access to complete health care I do indeed mean the pregnancy termination procedure in Irish hospitals followed by the aftercare, because that is the only appropriate way to perform any medical care. I do not know of any other aspect of medicine where we suggest that people would go to another country to have part of their care but we will look after them afterwards. As a general theme this is what we mean.

As regards a late diagnosis of the foetal abnormality and a patient travelling then, I absolutely agree it is true there will be more potential complications if the patient travels then. The uterus is much bigger. There is much more blood supply to the uterus later in pregnancy. There is much greater chance of significant bleeding. A patient travelling later in pregnancy is absolutely associated with much more risk. We would never like to see that happening but, unfortunately, it does.

As regards a perinatal autopsy, this is an absolutely crucial point. At present, since patients have to pay for everything themselves when they to go to the United Kingdom for termination of pregnancy they are often in a dreadful situation, having a certain amount of money to spend on the flights, hotel and basic procedure, and they just cannot afford an autopsy and special genetic testing. Unfortunately, they will decide they cannot do it. If the procedure was done in Ireland, public or private would make no difference as complete testing is done as part of the public health service. Patients in Ireland would have a total diagnosis.

Having a total diagnosis is crucial. Some genetic conditions have as much as a 25% or 50% chance of coming back again, whereas other conditions may have less than a 1% chance. I would think most families would want to know if the condition they have just gone through had a 25% or 1% chance of recurring. Additionally, the advent of preimplantation genetic diagnosis means that after certain types of genetic diagnoses are made, if a patient undergoes IVF, on the next pregnancy before the embryos are reimplanted it is possible to biopsy those embryos and find the ones that have the genetic condition and, crucially, the ones that do not, and then only replace an embryo that has been proven not to have the genetic condition. When a patient does not have this information as she cannot afford it because she is forced to undergo a procedure in a different jurisdiction, it has profound implications for her future fertility.

Dr. Rhona Mahony

As a supplementary, and coming back to the last two questions on aftercare, particularly on the taking of abortion pills, I re-emphasise to patients that if they present our primary consideration is to provide care for them. It is not just the physical consequences. There are also psychological consequences, and the circumstances in which a young person might choose to obtain tablets from a source she does not know and take them with all that risk, and why she is doing that on her own without accessing good medical care. I am referring to children, women of limited means who cannot travel and the other components and complexities that can exist for women who find themselves in a position where they do not want to be pregnant.

I re-emphasise the primary reason for foetal anomaly scanning is to identify treatable conditions in foetuses so when the babies are born we can optimise the care we give them. We know this can have a significant impact on survival. The classic example is congenital heart abnormality, where we are ready for the baby, we can institute the correct therapy, and the surgeons meet the mother in advance of delivery when plans can be made. It makes a big difference with regard to diaphragmatic hernia and gastroschisis for us to know the conditions are there so we can plan for the baby and enhance survival.

The Deputy is right that anomaly scanning is performed at 18 to 22 weeks. There is a cut-off limit in the UK at 24 weeks in general for termination of pregnancy. This can mean patients suddenly have to grapple with a diagnosis in which we say to them our experience tells us the baby will not survive. If they choose to make the decision to travel to the UK for termination of pregnancy they must make the phone calls, find the appointment and organise their travel, their children, their jobs and other elements of their lives. Unfortunately, there are big resource issues not just in Ireland but in the UK, and increasingly women face delays in the UK in areas such as Liverpool, which have provided a great deal of service to women in this context.

With regard to post mortems, we do not have very good perinatal services in Ireland. We have a very limited number of perinatal pathologists. It is a very specialised area. We are lucky in Holles Street and the Rotunda to have such specialised doctors and laboratory technicians, but this is not the case throughout the country. In many hospitals in Ireland there is a real difficulty at present in accessing post mortems. As Professor Malone said, this can make a big difference because some diseases have a significant recurrence rate and parents need to know this if they are going to embark on another pregnancy. The same goes for genetic services. We have very few perinatal clinical geneticists in this country, but if we look at how the technology is progressing, there is microarray and the ability to look at chromosomes and genetic material. We can now characterise the entire human genome. All of this technology is coming down the track, including the ability to edit the human genome, and we have very limited genetic services in this country.

I call Senator Ruane, who has six minutes.

I thank the delegates for their presentations. My first question does not arise because I consider it to be in any way attached to the issues concerning women who do not want to continue their pregnancy. However, as it has been a recurring theme in recent weeks, I am interested in the delegates' views on it. We often hear that Ireland is one of the safest countries in the world in which to be pregnant and give birth. Will the witnesses indicate how safety is assessed in Irish maternity care and whether we measure maternal morbidity as well as mortality? To reiterate, I see this as a separate issue, but the delegates are probably the best people to address the matter so that we do not have to hear it every week.

In his presentation, Professor Malone said that the Rotunda Hospital provides 10,000 20-week to 24-week scans for foetal anomaly and noted that many hospitals do not have the resources for such scanning. If all pregnant women are not undergoing such scanning due to inadequate resources, what are the factors determining which women are offered it and which are not?

In regard to conscientious objection, reference was made to how this might become a problem in smaller hospitals. What role do the delegates see for integrated services, including a role for GPs, in the future provision of termination of pregnancy services? Apart from cases of foetal anomaly and in a scenario where we are looking at an earlier stage in pregnancy - say, up to 12 weeks - and cases where termination of pregnancy is being entered into willingly, might there be a role for GPs in the provision of medications? How do the witnesses envisage the handling of conscious disagreement or objection in cases where a patient might be facing waiting lists to access a different GP? What types of issues might arise in such circumstances?

Dr. Rhona Mahony

On the question of maternal mortality and morbidity, we monitor those issues very closely. Indeed, the three Dublin maternity hospitals have been producing annual clinical reports for decades. In the case of the Rotunda, in fact, it probably has been done for more than 100 years or even 200 years. In addition to the year-to-year information, we can also plot the trends. At the moment, the maternal mortality rate is somewhere between eight and ten per 100,000, which compares very favourably with statistics internationally. In the United States, for example, where a much larger proportion of GDP is spent on the health budget, the maternal mortality rate is 17 per 100,000. In the United Kingdom, the rate is ten to 12 per 100,000, with similar rates in France and throughout Europe. In the Scandinavian countries, the rate is six to eight. We have, therefore, very low maternal mortality, although there are small differences there. Some 99% of maternal deaths occur in the developing world where mortality rates can be as high as 350 per 100,000 in any one country, which is a staggering figure.

In terms of maternal morbidity, approximately two women in every 1,000 pregnancies will have a very severe morbidity issue. These include massive obstetric haemorrhages, clots, venous thromboembolic disease, uterine rupture, etc. We have a list of very severe morbidities and we keep a record of their incidence nationally in conjunction with the National Perinatal Epidemiology Centre, NPEC, at University College Cork. Again, we can see certain trends from these data. If I were to comment on one such trend, it would be the rise in cases of haemorrhage. That is what worries me most as Master of the National Maternity Hospital, in particular the increasing incidence of postpartum haemorrhage. The other striking trend in terms of maternal morbidity is the increase in maternal age and maternal obesity, both of which have a significant impact on delivery and risk.

Professor Fergal Malone

The Senator referred to the prospect of more integrated services, perhaps at the primary care level and earlier in pregnancy. We are strong supporters of that concept. We want normal obstetrics to be delivered in the community as much as possible, by midwives and GPs, with the involvement of hospital obstetricians occurring only on an as-needed basis. That is the more efficient way to do things. However, that does leave open the potential, as the Senator observed, for situations where the local GP has a conscientious objection. The Medical Council is clear on this in that while doctors are entitled and allowed to have their own personal viewpoints and conscientious objections, there is an obligation on a doctor to ensure a patient is not disadvantaged as a consequence of any such view or objection. In such cases, there is an obligation to refer the patient to another doctor. I hope that would be done as efficiently as possible.

On the factors which dictate which patients receive scans, a crucial concept with foetal anomaly scanning is that it needs to be provided to all patients. Only a minority of foetal abnormalities occur in the setting of a previously affected pregnancy or a patient who has a strong family history. The vast majority of foetal abnormalities occur on a once-off basis where the couple in question had no previous idea such a problem might arise. We will only find those abnormalities if the scan is made available equally to everyone. It is not appropriate and not efficient to take just a certain age group or a certain disease category and provide a scan for those patients. That is one of the challenges we have in our health care system at the moment. In the RCSI hospital group, for example, of which the Rotunda is part, a new programme has been rolling out over the past month to resource foetal anomaly scans for Cavan General Hospital and Our Lady of Lourdes Hospital by way of the provision of a certain number of contract hours by newly appointed hospital group staff at those locations. We will see some improvements in that regard but it is a major deficit of the Irish health care system at this time.

The observation that services in the United Kingdom are under strain was made several times. Do the delegates have any particular concerns in that regard? I noted their points about the extra trauma caused to families by the need to travel. Has any consideration been given to the further trauma that would arise if parents have to travel beyond to the UK to a jurisdiction where English is not the first language? Are there possible implications in this regard arising from Brexit?

The delegates have raised very strongly the need to decriminalise the provision of pregnancy termination services. It is not one of the recommendations we are looking at, although I am increasingly of the view it will absolutely have to be centre stage. The witnesses described very clearly the chilling effect of the eighth amendment on clinicians. How is that issue addressed in gynaecological training? Is it something that comes up in the course of training young doctors?

We need to be somewhat careful when discussing resourcing issues. Do the delegates agree there already is an under-resourcing of maternity services? I am aware that claims for hundreds of millions of euro have been lodged against the State. Against that backdrop, we must be careful of saying that the provision of anomaly scans and abortion services will have resource implications. It is not an either-or situation. I am not saying the witnesses were suggesting otherwise, but we do need some clarity on the necessity of having adequate resources in place to provide best care for women in that context. It would be helpful if this issue were addressed today. The delegates' presentations were very clear and their standpoint as clinicians and medical practitioners, where they have said there is a risk to women and women's health by our continuing with current policy, could not have been clearer.

Dr. Rhona Mahony

On the resource issue, the fertility rate in Ireland is approximately 14 per 1,000, which is at the upper limit of European fertility norms. Yet we have the lowest number of obstetricians in the OECD, comprising some 140 to 150 whole-time equivalent posts. By any reasonable international standard, that number should be at least twice if not three times as large. In terms of midwifery services, last year we conducted a national study called Birthrate Plus which identified that Ireland's complement of midwives is 140 short, including a shortfall of 25 in my own hospital. That is a very serious deficit. The problem, however, is not confined to a shortfall in staffing provision. We also have a huge problem recruiting and retaining staff, which is a major issue, particularly outside Dublin. In fact, it is a global problem which exists across a range of countries and represents a real risk over the next ten to 20 years. We have just done a survey of doctors in training which found that very few of them want to work outside Dublin. Already, there are units outside the capital with very high locum dependency and experiencing great difficulties in attracting obstetricians. On the midwifery side, we have a particular problem recruiting midwives who are trained to scan and midwives or nurses qualified to work in theatre and in neonatal units. Again, these are very specialised areas and one cannot just go to market. These are people who trained for a long time and have very good skill levels.

On the one hand, then, there are these difficulties with resources and the fact the units are all very busy. Professor Malone and I each work in units delivering almost 9,000 babies per year. Arising out of that resourcing issue is a related problem.

Last year, the State paid €1.6 billion settling medical negligence claims. Some 60% of that was in obstetrics although internationally our outcomes compare favourably. Our health budget is approximately €13 billion. We do not have a direct budget for obstetrics but I estimate that it is not more than €1 billion. It is likely that we are now paying more money to settle medical negligence claims than we are using, despite the deficit, to resource our service in the first place.

I believe there is a need to decriminalise. A complex medical decision is being made and I am not aware of any other area of medicine where people are charged with making complex medical decisions under the shadow of a custodial sentence of 14 years. We had an opportunity in the Protection of Life During Pregnancy Act to decriminalise but we did not take that opportunity, which is a pity. I support the Royal College of Surgeons in Ireland's statement that medical procedures pertaining to women in pregnancy should be treated with the same regulation as any medical procedure and not in a criminal context.

On training, first we have a problem recruiting trainees to do obstetrics because it is such a high-risk area. It is a punitive area in Ireland in which to practise. People are becoming increasingly fearful of practising obstetrics in this country, which does not make women safer. We need to support the clinicians at the coal face who are delivering difficult care. Our primary aim when training young doctors and midwives is that they will be good clinicians and that their primary objective will be to provide good, sound clinical care.

On the strain in the UK, this year on International Women's Day, the Royal College of Obstetricians and Gynaecologists held a meeting dealing with issues surrounding termination of pregnancy. I was at the meeting. Much of it focused on the resource issues in the UK, which is also struggling to recruit doctors. It is a big issue for it too.

Professor Fergal Malone

To give a specific example of the strain in the UK, for a period of time one of the major units that we work with and which our patients attend was limiting Irish patients to one new Irish patient per week. That was for all of Ireland. We had quite a few examples of patients calling up and trying to make an appointment to find out that the one Irish appointment had already been taken. Then they would have to wait until the following week to try calling again and maybe it would be able to fit in the patient then. As the committee can imagine, it was a completely intolerable situation.

Deputy Daly asked about trauma for patients if they had to go farther afield. I am concerned about the impact of Brexit. If there are further practical impediments to patients travelling freely between Ireland and the United Kingdom, I would see some significant added traumas and challenges for our patients. It must be remembered that those who are must vulnerable to being traumatised are those who are non-English speaking. They are perhaps refugees who do not have the wherewithal or the common sense to be able to find other avenues for their care. It is a potential significant problem for us.

I thank both the witnesses for their presentation here today. We have met before at the health committees. Many of us here sit on the Joint Committee on Health where we discussed the national maternity strategy and its under-resourcing and how the outcomes we have in this country are miraculous given the low ratio of obstetricians to patients and the risks associated with our poor scanning. I think it was Professor Kenny from Cork who said one a week cannot be triaged so there are random instances of foetal abnormalities which one would not imagine would happen. We also have one child a week being born in circumstances that are not ideal. Under-resourcing of our maternity services has a massive knock-on effect, as the two witnesses know.

For the benefit of those listening in and members of the committee, will the witnesses clarify why the term "miscarriage" is used before a certain stage in foetal development and "stillbirth" used after? Why do doctors advise women not to announce their pregnancies until after the 12-week scan or the 12-week stage? What percentage of pregnancies end in miscarriage? How is a miscarriage recorded on a woman's medical chart in a hospital? It may be of value to the committee to know that, as a pharmacist, I have dispensed plenty of misoprostol in my time for people who have diagnosed miscarriages. It has been nailed down by medical professionals such as the witnesses. Therefore, on the idea that misoprostol is a drug that is not available, it is cheap and it is readily available. Perhaps the witnesses could elaborate on that for the benefit of the members of the committee.

It is obviously an area of specialty, but we have had claims at this committee and in public about foetal heartbeats developing at 21 days and foetuses jumping around. If they could to some extent and as broadly as possible, will they outline when the central nervous system of a baby develops and, with that, the ability to feel or sense things? When does a foetus become sentient? We have spoken about the earliest point at which a child has survived. Was it 24 weeks? I had not considered before the differences in the presentation at 24 weeks, where one could have weights of 700 g or 250 g. That was interesting and something I learned today. That it is not as simple as putting time limits on it is information of great value to the committee.

I thank the Deputy. We should allow-----

If I can finish, probably the most important thing the witnesses said here today is that it is a decision between a woman and her doctor. It will never become part of this committee's work unless we have a few obstetricians among us of whom I am unaware. The diagnosis of a fatal foetal abnormality is a complex procedure. From the witnesses' evidence today, it could involve a multiple of factors coming together. All of that can be helped by proper scanning as well as the maternal blood tests that are now available at eight weeks. We have heard in the Joint Committee on Health that some people may regard that as giving people options to perfect the child. However, what we have learned is that it gives the doctors dealing with the child all the necessary information to make the interventions that they need to make. I assume both witnesses entered medicine to save lives and that they specialised in obstetrics because they like handing people live babies. I thank them both for the work they do under very challenging circumstances.

I ask the witnesses to be brief as there is very little time remaining.

Professor Fergal Malone

With regard to the Deputy's last point on decision-making between the woman and the doctor, we want to preserve that as much as possible. I do not know of any other aspect of medicine - for instance, an oncologist sitting with a patient who is dying from cancer and his or her family - where they must involve outside agencies or legalities in the decision on when to stop offering further care. In paediatric care, when an unfortunate baby in the neo-natal intensive care unit is dying from prematurity, the paediatrician, the neonatologist and the family speak to each other, rationalise what is going on and together make a decision on when to withdraw care. That does not involve external agencies or any legal impediment. It is a common sense doctor-patient relationship and we want to do whatever we can to preserve it. Yet, in this aspect of foetal care there is an external force or cloud hanging over what can or cannot be done.

The Deputy asked about the terms "miscarriage" and "stillbirth". Traditionally, miscarriage is the loss of a pregnancy before viability at 24 weeks or 500 g. Stillbirth is the term beyond that. It is for that reason many obstetricians say and families decide not to tell other people that they are pregnant until after 12 weeks. It is because most spontaneous miscarriages will reveal themselves by then.

The Deputy asked for a percentage. About 30% to 40% of all human conceptions will end in a miscarriage. If the patient reaches 12 weeks, they can generally be very confident that at that stage it is highly unlikely to be a miscarriage. The Deputy asked how that is recorded. It is simply recorded as a miscarriage; that is the term we would use.

I am aware some hospitals use the term "abortion" on a chart.

Professor Fergal Malone

Not any more. We would use the term "miscarriage". We would be sensitive to that. In other countries, and in some textbooks, "spontaneous abortion" is a term that is used. It is synonymous with miscarriage. Most people here do not like to use that term and prefer to use the term "miscarriage".

The Deputy asked a very pertinent question, which was when central nervous system, CNS, development occurs in the foetus. About two years ago, the Royal College of Obstetricians and Gynaecologists convened a working group, bringing together various neurologists and physiologists, to specifically examine that. It was about the sense of pain and when a foetus might feel pain and it was clear from the consensus among a wide range of disciplines that that does not occur before 24 weeks and is probably closer to 30 weeks. It is a mistake to assume that just because an ex-25 week foetus in the neonatal intensive care unit can show signs of feeling pain that the same 25-week foetus in utero will feel pain. That is a very different environment and the consensus from that working group was that it is certainly beyond 24 weeks gestation, if not closer to 30 weeks.

Dr. Rhona Mahony

I would make one brief comment relating to the 12 weeks and miscarriage. The first trimester, the first 14 weeks of pregnancy, is when the risk of miscarriage is highest. It is about one in five pregnancies and the vast majority of those cases, about 80% or 85%, are related to chromosomal abnormality. Miscarriage is much less common in the second trimester, which is between 14 weeks and 24 weeks, but we can have issues like antiphospholipid syndrome or sticky blood syndromes, infection and cervical incompetence, but it is much rarer. Stillbirth after 24 weeks is very rare. We are looking at instances of about two to three per 1,000. The 12 week issue comes from the fact that at least one in five pregnancies will end in miscarriage in the first trimester.

Could one of the witnesses clarify the position about the heart or the heartbeat?

Dr. Rhona Mahony

The heart begins to develop as a tube very early on in pregnancy but then it must develop into the chambers. Although much of the development is complete by 12 weeks, it still has to grow and develop normally, so it is not sufficient to say that just because a heart starts to beat that its development is complete.

I call Senator Buttimer, who has six minutes.

I thank the witnesses for coming in to share their knowledge with us. Dr. Mahony spoke a lot about the criminal law but I think she would accept that even in Britain there is a criminal law restricting abortion, that doctors are subject to the criminal law in Britain and that, in general terms, the criminal law is part of helping society distinguish between rogue and good doctors. Would she accept that the fact that there is no case law in Ireland showing that doctors have been found wanting or have been subjected to the criminal law suggests that the balance has been got fairly right and that, in general, there is a reluctance to second-guess a judgment made by a doctor, particularly given that the risk to life does not have to be imminent? The balance seems to be well struck if the witnesses are not able to cite case law about how doctors found themselves in trouble in this area.

This is an issue about balancing risk, and the witnesses are experts in that, but it is also a question about values and it seems to me that how they view abortion generally will impact on their views about how to manage risk in this area. Are there aspects of the British abortion law that they find unethical or that shock the witnesses? I may have misunderstood Dr. Mahony to say that 24 weeks was the cut-off point where there was a question of a disability and that that was exercising pressure. My understanding is that the relevant ground in the British law, and please correct me if I am wrong, does not specify a time limit and that is why there have been cases of children with disabilities as minor as cleft palate being aborted very late term in Britain. I would like the witnesses to tell us where they are coming from because it is not just about medical expertise. There is an interaction with values, particularly as it seems that it is only in recent years we hear expert doctors in Ireland talking about all of these matters. Ten years ago when, presumably, we knew less in medicine, and I am asking both witnesses to address these questions. Doctors seemed to be happy that there was this balance in our law that allowed them to care for two patients. I have not heard that kind of narrative in what the witnesses have said today.

On the question of foetal abnormality, and I think Professor Malone excludes the term "fatal" from what he is seeking to be lawful - please correct me if I am wrong - do the witnesses accept the testimony of families who believe that where their child was diagnosed with what has been called fatal foetal abnormality, it was not just a matter of their choice as parents being respected in terms of whichever road they took but that they felt that their child had a right to be respected until their natural end? Do the witnesses accept that there is nothing they can say to convince those people because they see it as a right their little child had, particularly when we think that what might happen to that child in the context of a termination would be the injection of potassium chloride into the child's heart preparatory to the termination? Please correct me if I am mistaken about that. Would they accept that they find that impossible to relate to any notion of respect for that child?

Regarding choreoamnionitis, I am a little confused. I would like to know first whether Professor Malone is completely of one view with Dr. Mahony on this issue. I have spoken with some midwives, and the witnesses might tell me who is wrong on this, who have been surprised by Dr. Mahony's claim that doctors must simply wait until an infection occurs. They cite, for example, the Health Service Executive's 2015 guidelines on chorioamnionitis, which state that women with clinical signs of chorioamneonitis should be commenced on broad spectrum intravenous antibiotics and that delivery should be undertaken. Given that this is not an issue, and the witnesses can correct me if I am wrong, where I imagine a person would have to go abroad - they would be too sick - it appears to be the case that the current legal architecture is allowing doctors to do what they have to do.

Do the witnesses believe that 48 hours is reasonable in terms of blood culture results? Is that reasonable or a sign of an inadequacy in terms of resources? Could that period be shortened? Is it desirable that it be shortened? Would that be a help? However, the main question is whether there is a problem here if the witnesses appear to be dealing with this situation very well. We have not heard of sad cases.

Dr. Rhona Mahony

The Senator asked a lot of questions.

We have very little time left for answers.

Dr. Rhona Mahony

Very briefly, in regard to the UK, the Senator is right. There are situations where termination of pregnancy in the UK is a criminal offence. In fact, that is currently the big debate in the UK and, as I said in my position statement, the council of the Royal College of Obstetricians and Gynaecologists have voted strongly in favour of supporting the removal of criminal sanctions associated with abortion in the UK. They say that they believe the procedure should be subject to regulatory and professional standards in line with other medical procedures but not criminal sanction.

As for helping society distinguish between rogue and bad doctors and there being no case law of doctors being arrested and put in prison, the point is that the law is there and we must, and will, abide by the law. In my practice I will abide by the law but to my mind the law is unclear in regard to determining when a woman is sick enough to qualify for the substantial risk to her life provision. It is not enough to merely say that in the past couple of years no doctor has been prosecuted. Doctors have been prosecuted in Northern Ireland, but the law remains as it is and that is the law under which we practice medicine today.

What have they been prosecuted for in Northern Ireland?

Dr. Rhona Mahony

In regard to termination of pregnancy, and one could look at UK law, but there have been one or two cases where doctors have been accused of inappropriate termination of pregnancy-----

On their assessment of the risk or on a completely different ground?

Dr. Rhona Mahony

On different grounds, yes.

That is different from assessment of risk.

Dr. Rhona Mahony

The point is that the law exists in this country that a woman qualifies for a termination of pregnancy in the case that there is a substantial risk to her life that can be removed only by termination of pregnancy.

I have outlined very clearly the challenges that creates medically. Whether anybody has been put in jail is not the point.

Dr. Rhona Mahony

The point is what is the law under which we practise.

In respect of ruptured membranes, when I say it takes 48 hours to obtain a microbiology culture, that is not a deficiency. It is just what it is. Some more rapid tests are becoming available in which we can look at polymerase chain reaction, PCR, or viral material directly in the laboratory and get quicker results, but at present, for practical purposes, it takes us 48 hours to get confirmation on a laboratory specimen, to actually grow the bugs to determine that there is chorioamnionitis. Therefore, we make our clinical decision based on clinical signs and symptoms that might suggest there is chorioamnionitis. It is most likely to occur in the case of a ruptured membrane and the signs and symptoms of infection we look for are temperature, rapid pulse rate, hypotension, all of the things we measure all the time. The difficulty is that infection can be sub-clinical and when it does take hold, the clinical course can be very rapid and women can become very sick.

The HSE guidelines, therefore, are not enough. Is that what Dr. Mahony is saying? They do not protect the doctor.

Dr. Rhona Mahony

No. It is about clinical care. My point is that one cannot predict a clinical course with precision. Some women will get sick gradually and not very sick. Some will very quickly become very ill. In that context, one is facing performing a termination of pregnancy on a woman who is unstable, has major sepsis and is very ill. That can happen when the membranes have ruptured at 14 weeks when there is little prospect of foetal viability.

Is that Professor Malone's view also?

Professor Fergal Malone

I completely agree with Dr. Mahony that when the clinical signs of chorioamnionitis are present, it is a very easy diagnosis to make. The HSE guideline, as the Senator quoted accurately, is to get on with providing care and carry on with a pregnancy termination. The point is that sub-clinical chorioamnionitis is a real issue. Patients often do not show they have a temperature or tachychardia, fast heart rate, foul-smelling fluid or a tender abdomen until much later in the course. If a patient has ruptured membranes for 14, 15 or 16 weeks, she could well be developing it. She has virtually no prospect of getting to a gestational age at which she will have a live baby, yet brewing inside her, without showing any sign of clinical infection, there can be a serious infection. It is a real issue.

The doctor is not permitted to intervene at that point. Is that what Professor Malone is saying?

Professor Fergal Malone

Absolutely because on a reading of the guideline, as the Senator quoted correctly, the clinical signs are present, but the point is there can be an infection much earlier. We will take that risk if the patient is at 23, 24 or 25 weeks, on the cusp of viability and we might just get there. Let us take that risk together. When the patient is at 14 or 15 weeks and has another ten weeks before there is even a chance of viability, the balance is very hard to justify. It does restrict us.

The Senator expresses surprise that some families who have carried a baby with fatal abnormalities and have had those special moments after birth would have a hard time reconciling with the idea of a termination for fatal foetal abnormalities. I agree completely with him and absolutely accept that there are some parents who follow that journey who would find what we are talking about appalling and could never conceive of the idea of terminating their pregnancies, but equally there are many patients who when they are told at 12 or 14 weeks that, unfortunately, their baby has no head and no upper brain, that there is nothing we can do about it, that they must wait another four, five or six months before we can, find it equally appalling. I am here to tell the committee that we would like to care for all of our patients, irrespective of what is their personal, moral, religious or ethical background. One group of patients has a care pathway that it can follow, but another does not.

I thank the delegates for their presentations. Do they think palliative care or hospice services for those who wish to continue with a pregnancy where life after birth is likely to be short are equal throughout the country? How difficult is it for staff to provide appropriate non-directive counselling for a woman seeking an abortion under the current legislation and what impact does it have on the clinical care and best practice in caring for women and children?

Professor Fergal Malone

Perinatal hospice care is a very well developed concept, but like all aspects of the health care system, it is subject to limitations on resources. It is not a surprise that there would not be similar resources around the country. Some aspects of perinatal hospice care are quite specialised. The HSE has recently published bereavement standards in which they are trying to make clear the minimum standards for personnel required to help and support families who are following that journey. It will allow hospitals to measure themselves against those standards. Where it is clear that there is a deficit in numbers of personnel, at least we will be able to address that issue. I would not go so far as to say it is equal around the country; it is not.

Providing non-directive counselling is part of one's professional training. We train midwives and obstetricians and show them how to leave their own opinions at the door, to not reveal their own personal viewpoints. It can be hard as we are all human, have our own sets of beliefs and, as Senator Rónán Mullen said, values. They are real and heartfelt, but when dealing with a patient without knowing what her value system is or her moral, religious or ethical viewpoint, our value systems and views have no place in the discussion. Training is required and we provide that training for our staff.

Dr. Rhona Mahony

I agree. We are just starting to develop really good perinatal hospice care services in terms of the ancillary multidisciplinary care we need to provide. It is not just a matter for doctors and midwives but also involves social workers and bereavement counsellors. We are seeing lovely developments in capturing memories for couples, a sort of anticipatory grief when we know that it will be a very difficult time for them. We are learning from patients' experiences and engaging with patients and trying to understand what has made a good positive difference and where perhaps we have said the wrong thing or not done the right thing. Part of the conversation in Ireland in the past few years has also focused our minds on improving care for those women who do stay at home to continue with their pregnancy. We increasingly understand the difference providing really good care, not just for the woman but also for her family, can make. That is a very positive development.

As doctors, our job is to provide the information, make the diagnosis and provide the benefit of what information and clinical experience is available in order that patients are informed to make their decisions. If I have a value system, it is absolutely the provision of safe clinical care for women and infants in this country.

I welcome the two delegates. Professor Malone told the Irish Examiner that in the majority of cases in the Rotunda Hospital where babies had been diagnosed with anencephaly or trisomy 18, parents travelled to Britain for an abortion. That is in sharp contrast to the findings of research from Cork University Maternity Hospital where more than 90% of parents who had received a diagnosis of trisomy 18 continued with the pregnancy. Cork University Maternity Hospital also found that most parents continued with the pregnancy after a diagnosis of anencephaly. What is the Rotunda Hospital doing wrong? Do parents feel unsupported in the hospital?

Are the delegates aware of findings in a study by Duke University in 2015, published in the peer reviewed journal Prenatal Diagnosis, that women who underwent an abortion after a diagnosis of anencephaly were significantly more likely to suffer from depression and even despair than those who continued with the pregnancy? If Professor Malone is aware of this, did it influence his clinical practice?

On his statement that he leaves his views at the door, medicine has always been about values. Does he believe preborn babies with a disability have less of a right to life?

I also have some questions for Dr. Mahony.

Professor Fergal Malone

I believe the Rotunda Hospital is providing services to the utmost level of quality and could be easily standardised or benchmarked against international best practice.

I will not comment on the experience of other hospitals with pregnancy termination because I am not in a position to do so. I can tell the committee the statistics I quoted, which show that about 57% of our patients with a prenatal diagnosis of Down's syndrome do travel for a termination of pregnancy and 50% with a diagnosis of trisomy 18 travel for a termination of pregnancy but 50% do not. To me, this demonstrates absolutely good and balanced counselling of patients. Almost an equal number of patients who are diagnosed with trisomy 18 or trisomy 21 in the Rotunda choose to continue as compared to those who choose not to. One cannot get any more balanced that. If I had statistics that were 99%, 1% one way or the other, that would raise the question of someone else doing something wrong in terms of their balance. I do not think our numbers could be any more balanced than what we are seeing.

The Deputy referenced the study in Prenatal Diagnosis. I am very familiar with the study by Cope and colleagues that suggested that there was an increased incidence of various measures of psychological trauma or upset after they terminated for various abnormalities. I would not accept that paper as being a good example to learn from. When one looks at the methodology in that paper, one can see that many of the patients who were recruited came from social media campaigns or were tracked down or recruited through social media. As a clinician scientist, and I carry out and have published a lot of research studies, how one recruits patients into a study is crucial to the outcome. If one recruits patients who might have a certain viewpoint already and go to social media to recruit them into the study, it is not all surprising if the results are in a particular direction. The unbiased recruitment of patients is crucial to any science in any speciality. That would be my concern about the Cope paper cited by the Deputy.

I believe all of our patients have rights to health, well-being and dignity and that is what we strive to do day in and day out with our patients. We listen to our patients and what their personal values are and provide them with the information. One set of parents might decide in one direction while another might decide in another direction and that is okay. That is acceptable because it is our job to be professional and I think we continue to do that.

I have some questions.

The Deputy should ask one question if possible to keep somewhere near his time.

Dr. Mahony said previously that abortion should be legalised on health grounds. For what specific conditions would she recommend that women undergo an abortion on health grounds? Has it been her experience in her clinical practice that she has delivered sup-optimal care to a patient or patients because she could not perform an abortion on health grounds?

Dr. Rhona Mahony

It would be impossible and would not be wise to provide a comprehensive list of either conditions that can kill someone or cause adverse health outcomes. The point is that in any clinical course, doctors are able to make sensible clinical decisions that will result in a woman maintaining good health and staying alive. There are times in pregnancy when complications occur that can put a woman's life at risk and can cause serious disorder. The difficulty sometimes is ascertaining the difference between someone being very sick and someone dying. That can be difficult to predict with precision. What doctors and their patients require is the flexibility to work together in the context of clinical disease in pregnancy to make good sound decisions that will ensure that women are safe.

Just one brief question.

In 2013, 15 obstetricians who had been practising in Ireland for many years under the eighth amendment wrote to the Oireachtas committee, of which I was a member, strongly disagreeing with Dr. Mahony's claims regarding fears of a prison sentence for intervening to save a mother's life. One went on to describe those claims as histrionic. At those Oireachtas committee hearings in 2013, in answer to Senator John Crown, Dr. Mahony and other obstetricians agreed that they did not know of any instance where a needless maternal death had occurred because doctors had felt unable to act to save a woman's life under the eighth amendment. Is it fair to say that Dr. Mahony may be ideologically motivated in calling for abortion to be legalised in Ireland?

I think that question may already have been addressed.

Dr. Rhona Mahony

The word "histrionic" is quite interesting in respect of a female gynaecologist.

I have two questions, which are follow-ups from answers the witnesses gave to previous speakers. We are all aware of the costs of travelling and the fact that they are prohibitive for some women. If I understood Professor Malone correctly, he said that in some cases where there was a fatal foetal abnormality, the cost factor in terms of autopsies and further testing might deter a woman from having testing done that might have facilitated her to have a successful pregnancy thereafter and a baby that could be delivered and would live. Could he clarify that because that is something I certainly had thought about before?

My second question is a follow-up to Deputy Daly's question about training. Both witnesses are both Masters and senior clinicians but in terms of people not wanting to go into the profession partly because of the criminalisation issue and also having to make those decisions around when it is a risk to health and when it becomes a risk to life, does that also deter people coming from other jurisdictions who would not have grown up under the eighth amendment from taking the risk of taking a job in obstetrics and gynaecology in Ireland because of the issues around the eighth amendment?

Professor Fergal Malone

The Deputy's initial question is a very real concern and we have had experience with it. A patient goes to the UK, has a pregnancy termination and we do not have a clear diagnosis when she leaves. What would have happened in Ireland is an autopsy with some extensive genetic testing. In respect of some of the newer genetic tests, an individual genetic test can cost €500, €600 or €800 for one test so that would be done here and in many cases, we get an answer. However, if the patient is in the UK and is not entitled to free care on the NHS because she is not registered as an NHS patient - she is an Irish patient - and she wants that testing, she will have to pay for it. Some parents will pay for it because it is medically crucial information but we know some patients already struggle to reach the €800 to €1,500 a termination in the UK costs and now also have to find another €500, €1,000 or €1,500. We have had parents who have decided not to have the relevant testing done and are then left with an incomplete diagnosis - "my baby died because of a brain abnormality but we are not exactly sure what kind of brain abnormality" - and they have no idea what the chances of it coming back again are so it is a real issue and would be one that would not be there if we could undertake the complete care for our patients here.

As regards training, it is important to differentiate between doctors in training and a senior consultant of 60 or 65 years of age who has been around the block for 20 or 30 years. The self-confidence that comes with being a clinician who is 60 years of age and who can make a stand and say, "This is what I am going to do" is very different to a 24 or 25-year-old intern or SHO. It is expecting a young inexperienced doctor to have such a spine as to say, "You know what, I don't care what the criminal code says. This is the right thing to do and I'm going to do it". I can see a 60 or 65-year-old experienced clinician saying, "That is what I am going to do" and the legislation not having a chilling effect on them but it is very different for a doctor in training, so I do think it has an impact. One of the earlier questions suggested that other doctors have come into the committee and said that they do not see that as a problem. That is great and that comes with 20, 30 or 40 years of practice but these are not necessarily the doctors at the coal-face at 2 a.m.

Dr. Rhona Mahony

It is important to note that we generally work as a team and if there is a complex medical issue, consultants and trainees work together and, generally, consultants have a really big input when a patient is unwell or where there are complex clinical issues, so I would like to think that it is very rare that a trainee would find themselves on their own in this context. We generally work very hard to work as teams but there is a broader issue regarding training. It is not just the chilling effect of the eighth amendment. There are broader issues relating to obstetrics, recruitment into training and attrition rates.

That is because obstetrics is very high risk. We have long hours. It is a surgical specialty. Complications can arise, not necessarily due to somebody's fault, but they can arise unpredictably and they can be very profound.

In terms of adverse outcome, our specialty experiences maternal death, the death of baby or a baby who is very damaged and has cerebral palsy. These are very high-risk stakes. For some young people, these kinds of outcomes will make them wish not to practise in obstetric medicine. On top of that, it is quite punitive to practice in Ireland. We have a good deal of regulation, which is a good thing but, at the same time, if there is an adverse outcome, one can face into a High Court litigation, a civil litigation, or a Medical Council hearing. Perhaps one of the most difficult aspects is the fact that Medical Council hearings or other cases are covered in the media, and that is very difficult when one lives in a country with a population of 4.7 million and one sees one's name regarding a case or very intimate details of cases being published.

Ireland is a little different with respect to women and women's health regarding the intimate details about women, particularly in the area of termination of pregnancy, that find their way into the newspapers. At times I have been quite shocked at the level of the detail because it makes women readily identifiable. Also, we do not tend to see similar reporting with respect to men, for example, having prostate surgery. There is a bias there. That can frighten young doctors. Certainly when we see cases like the Y case or other very high-profile cases, no doctor wants to find himself or herself as part of the next media sensation. We never want to be part of an adverse outcome, but they will happen because our specialty is very high risk, and even though we do our very best, we will have complications and adverse outcomes. Ireland is a punitive place in which to practise medicine, and that puts some of our young people off doing so.

Most of my questions have been answered. The Protection of Life During Pregnancy Act, which is on the Statute Book, provides for a 14-year custodial sentence both for clinicians and for people who procure abortion through abortion tablets. I spoke on that legislation in the Dáil and I opposed that measure, but I still cannot get my head around the idea or perception of a young girl in a bedroom in some part of this country, frightened, fearful and pregnant, taking abortion tablets, and the potential chilling effect, because it is a criminal offence, that has on that girl seeking medical help afterwards. As clinicians, do the witnesses believe that is potentially detrimental to a girl's health or life? Does it drive a wedge between the girl's relationship with her doctor because of the fact that it is a criminal offence? The witnesses might elaborate on that. In view of what is happening in Northern Ireland in the context of the seizure of abortion pills and prosecutions, do the witnesses believe that is putting at risk the health or lives of young girls especially because they might be fearful of going to a doctor thereafter?

Dr. Rhona Mahony

That is really good point. The first thing I would say to any young woman, no matter what has happened and if she has taken these tablets, is bleeding and in trouble, is to go hospital and have appropriate care. We are not going to prosecute her. Our primary objective as doctors in a hospital is to keep her safe and provide good clinical care. That is an important message to send out to all young women.

I agree with the Deputy that I worry about vulnerable young women who find themselves in such circumstances and have resource to the Internet to obtain tablets that will induce a termination of pregnancy. Apart from the fact that one does not know what one is taking when one gets tablets over the Internet, which is a very important public health message because people get all kinds of tablets over the Internet, on top of that, there is not the support for women to navigate those circumstances. I think particularly of children and young women who are making these decisions on their own and the psychological impact such decisions might have on them. It is important that, when required, women, access health services. We are in business of providing safe health care for patients. That is absolutely paramount.

I call Deputy Coppinger and she has six minutes.

I will start with the last point because in the previous session we had a presentation about abortion pills and the research that has been done. Obviously, they are used for 80% of abortions in Finland and are medically extremely safe, but I am sure the witnesses would agree it would be much better if women in Ireland could go to their GP, have a discussion and be prescribed them, as they can be prescribed to women in practically every other country in Europe. We might be sending out the message that they are quite safe. According to the research that we heard about earlier, about 4% of women had to seek help because they were not sure if they had completed an abortion.

My questions relate to the hospital system. Why do the witnesses think the level of testing in Ireland is so poor? Obviously, cost must be a huge factor, but is the position of the Catholic Church a factor as well in the sense that pregnant women getting tested for abnormalities of any kind has been definitely discouraged. That certainly was my experience. Different hospitals have different positions on it. Given the level of such testing is very poor and many women do not get access to the system until 23 or 24 weeks, would the witnesses agree that there cannot be a time limit if abortion is legalised for a fatal foetal abnormality? Otherwise, we would be excluding those people who have been disadvantaged through an accident of where they happen to be situated.

Professor Malone said in his presentation that it is now possible to detect to 95% to 99% of foetal chromosomal abnormalities as early as nine to ten weeks of pregnancy. Therefore, we could be detecting these issues much earlier and making the whole trauma for a pregnant woman completely different. What would be the cost involved in testing? As it involves just a blood test, it is hard to understand why it costs so much.

Have either of the witnesses encountered women who were not able to access a termination because they could not afford to go to England, and what has happened to those women who were so diagnosed? Would they have encountered women in their clinics who are pregnant and where there is not a fatal foetal abnormality but who would like to have an abortion because, as in the case of the 62% of the women who have used abortion pills, they are mothers already, they have children and they know what it is like to be pregnant, to give birth and to bring up a child? Would they have encountered such women or are they just too afraid to talk to the witnesses about that?

On the issue which has been raised of the chilling effect on doctors, I was struck by Professor Malone saying in his presentation that doctors cannot even pick up a phone and make a referral. That says it all to me. The procedure is perfectly legal in Britain but yet he is not allowed to ring another doctor in Britain and make a referral. Is that not going beyond the bounds of the eighth amendment, or is it just that doctors are too afraid to challenge it in any way?

On the issue of maternal deaths, we regularly hear that Ireland is the safest place in the world in which to have a baby, but generally it is not people who have had a baby in Ireland who say that. There has been an increase in maternal deaths. Dr. Mahony gave some of the reasons for that in terms of women being older, obesity being a factor, etc. Are the witnesses very concerned that migrant women and non-Irish women are showing up disproportionately in those deaths? Does that not say something about perhaps their having less access to health care or getting it later? Are the witnesses happy that those women are being listened to? Are there cultural issues involved as well? Even in the case of Savita or other women, perhaps their wishes are being listened to and they are being told this is the Irish situation.

The Deputy might need to let the witnesses respond.

I wish to ask one last question about Down's syndrome, because it is something which is constantly raised in the committee. It was said at this committee that Denmark has a goal of eradicating Down's syndrome. That might be news to people in Denmark. In a debate in which I took part with Ms Cora Sherlock from the pro-life campaign it was claimed that 90% of pregnancies in which Down's syndrome is diagnosed are aborted. My figure was 44%, which is quite near to the percentage given by Professor Malone. I am raising this issue because this is a parliamentary committee and we should be able to fact check and challenge claims.

Professor Fergal Malone

The Deputy had some specific questions on the cots of the blood test which is done at nine or ten weeks. It currently costs about €350 per blood test, but that is partly because the intellectual property and patent is owned by some international genetic companies which have a certain amount of profit built in to the tests. That is business.

If we could have a genetic sequencer and the required laboratory technology here, I am confident that the test could be performed at as low a cost of €150 or €100. The cost could be reduced considerably if we developed an appropriate genetic laboratory here. At the moment, patients have to pay about €350 because a sample is sent to commercial laboratories in the United States or London.

On the comment that doctors cannot even lift a telephone to make a referral, that is true. There is a ridiculous situation now whereby some doctors are using euphemisms. They will write a letter to another doctor in the United Kingdom and ask him or her to see a patient with anencephaly for a second opinion. It is a euphemism for saying that he or she is not sending a patient over for a termination of pregnancy because that would be a referral, but is instead asking for a second opinion. That is the cover people are trying to use because they are concerned about how the legislation is written. It is real and changes how communication happens.

Migrant women and women who come to any country from another country are probably more at risk in terms of maternal health and well-being and are probably over-represented in statistics for maternal morbidity and mortality because they have a hard time accessing services or trusting that they can access services. We would like the message to go out, as Dr. Mahony said, that if a patient takes medication at home to bring on a pregnancy termination and runs into trouble, we want her to present to a hospital immediately. We will certainly not be looking to refer or report a patient to authorities. Rather, we just want to care for patients.

The reality is that some patients from other countries may not be comfortable with the fact that the doctor or health care system may be somehow complicit with the justice system and they will be reported. We would not do that. We care for patients.

Might some doctors make such reports?

Professor Fergal Malone

I can tell the Deputy the practice in the Rotunda. We are here to care for patients. We are not here to police the system or anything of that nature.

The Deputy's figures are correct. I quoted the 2016 figures in the Rotunda for cases of Down's syndrome. We have no goal of eradicating Down's syndrome. As said, nearly 50% of our patients choose to continue and value their pregnancies. I have seen patients with more than one baby with Down's syndrome and we embrace and support that. It is a wonderful thing. We have no goal of eradicating from society any group of patients. We are here to care for patients. That is all.

On an important point of order, a reference was made to a third party, Ms Cora Sherlock of the pro-life campaign, who I happen to know. I would be fairly sure that she was referring to 90% as the figure for Britain, which makes its own point about what happens once this is legalised. Whether I am correct in that, it is utterly unfair that it would be alleged that a third party got her facts wrong. I am fairly sure she did not, but she should not have been referred to in any event by my colleague. I ask the Chairman not just to note that but to agree with me in regard to references to third parties.

I would agree with that in respect of references to third parties. That is a long-standing practice in the Houses of the Oireachtas.

I thank the Chairman.

I would request that perhaps the Senator invite Ms Sherlock to write in and clarify the position if she wishes to do so.

She does not need to, in fact.

It is something which Ms Justice Laffoy did and I was quite happy to read out a clarification.

Okay. I appreciate the Chairman giving me the opportunity to make that a point of order.

I am happy to clarify any particular issue.

Dr. Rhona Mahony

I wish to make a couple of points on medication and abortion pills. There is a safety record when the correct tablets are taken correctly. However, when medication is obtained over the Internet, its source is not known, which is a risk.

In addition, occasionally people have ectopic pregnancies, where a pregnancy has occurred in the tube and not the womb. That can cause significant risk in terms of misdiagnosis. It is much better that care is offered with a degree of expertise and women are not completely going it alone in terms of care during pregnancy.

On perinatal testing, first trimester screening looks at chromosomal anomalies, specifically trisomy 21 or Down's syndrome, Edward's syndrome and Patau syndrome. The test is currently about €350. The number of women accessing it in Holles Street has increased. When the test was first introduced three years ago, two or three women requested it and now more than 1,000 do so. There is a significant cost which means that women of limited means are not able to afford the test.

The commonest prenatal diagnostic test is ultrasound. In my experience, most women will opt to have a foetal ultrasound. Very few women refuse or decline ultrasound during pregnancy. The reason we have ultrasound is to be able to give the best possible care to a baby where an anomaly has been identified and we can prepare for birth. It is an important reason we look for foetal anomaly.

In terms of maternal mortality and morbidity, we looked at morbidity and I agree with Professor Malone that people of different ethnicities have different outcomes. There is no doubt that it is not enough to look at maternal mortality because those numbers are small and have been relatively stable over recent triennials.

Women of different ethnicities are disproportionately represented in terms of morbidity for all of the reasons outlined by Professor Malone. These include access to care and perhaps not coming for antenatal care. Some women, by virtue of their ethnicity, naturally have an increased risk of pre-eclampsia or fibroid uterus which poses attendant risk.

On the idea that Ireland is the safest place in which to give birth, I do not think people would say it and it is not a sensible approach. The point is that we monitor the data and check outcomes constantly. One should not practise clinical medicine unless one is looking at outcomes. We are trying to identify trends. I referred earlier to my concern about the trend of increasing haemorrhage, for example. We are trying to monitor such trends in order that we can safeguard women in the future and plan our services to provide the best possible care given the current challenges faced by any health service.

I wish to make a brief comment on Down's syndrome. It is not one condition. There is a spectrum of disorder in Down's syndrome. Some children with Down's syndrome will be born very healthy. Others have very serious cardiac or other defects which mean they will not survive in utero or will die very soon after birth. We have to take that into account. It is very likely that it comes into account when women are making decisions regarding termination of pregnancy. It is not simply one disorder. Infants with Down's syndrome can have a broad spectrum of challenges.

I thank Dr. Mahony.

I thank the witnesses for their contributions. They have been very informative and helpful. In terms of the status quo, there is a difference between decriminalisation and legalisation. Professor Malone and Dr. Mahony are professionals. There is the Medical Council, the Constitution and so on. Does decriminalisation add anything to the regulatory regime? If abortion were decriminalised tomorrow, would doctors suddenly start acting in a legal matter?

Dr. Rhona Mahony

Decriminalisation would have an impact. I quoted the High Court case of 2014. It is a direct effect of the law which pertains. If we did not have the prospect of a custodial sentence, the decision-making in that case could have been very different. At times, doctors would be a lot more comfortable with intervening earlier in cases where there is substantial risk to the health and life of a woman if they did not face a custodial sentence.

Criminalisation has the capacity to distort and delay clinical decision-making, which is very important. That is not to say, like any other medical procedure or practice, that it should not be regulated appropriately. Nobody should or would argue any differently on that. I am not a lawyer so all I will say on legislation is that what we as doctors are seeking is that the law of our country allow us the flexibility to make the best clinical decisions for our patients.

The Citizens' Assembly has recommended 12 different sets of circumstances. How would the witnesses deal with the introduction of extensive, complex legislation from a professional perspective? They are not judges or lawyers and decisions often have to be made very quickly. Do obstetricians get training? Does the Medical Council provide advice? Do situations arise where different hospitals might take different positions? How, on the whole, do doctors deal with complex legal situations like this?

Dr. Rhona Mahony

The first thing to say is that doctors are very regulated. We have not just Medical Council guidelines but also HSE and national guidelines to help and assist us to provide optimum care to our patients. We cannot be negligent: we have to provide good, sound clinical care and there is good regulation in this country to ensure that doctors practise appropriately. The issue with obstetric medicine is that not a lot of other areas of medicine have an insert in the Constitution that has such an effect on clinical practice. Going back to the 1983 referendum, there was difficulty in choosing that wording and trying to determine its consequences. The number of subsequent referenda that have taken place - on the right to information, for example, or the right to travel - shows that we have done more or less everything to circumnavigate this issue without actually dealing with the effect of the eighth amendment on clinical care. This is something that Ireland really needs to deal with because I believe that the presence of the eighth amendment in the Constitution creates substantial clinical risk.

There are other options. There are many different examples all over Europe of countries choosing to legislate in different ways, from highly restrictive legislation in countries like Malta; fairly restrictive legislation in Germany; to more open legislation in other countries. It is really for the people of Ireland to decide on the legislation. Whatever path is chosen, what we as doctors require is clinical flexibility in order that women and their doctors can make appropriate decisions in the very difficult circumstances that arise from complications in pregnancy.

Professor Fergal Malone

There are very clear mechanisms in place for new guidelines and changes in legislation to be rolled out, particularly in obstetrics and gynaecology. The Institute of Obstetricians and Gynaecologists works with a national clinical programme office in updating guidelines. The Medical Council will regularly review its own ethical guidelines in light of legislative changes and there are regular meetings at which obstetricians review and update new guidelines. These can generally be disseminated quite quickly across all 19 maternity units. There are systems in place, then, that will allow for a fairly rapid roll-out of a change in guidelines or practice.

What is the rate of maternal death in the total absence of maternity care? In other words, how inherently dangerous is pregnancy?

Dr. Rhona Mahony

That is a great question. I have spent time in Sierra Leone, Malawi and Tanzania, countries with very little by way of assisted childbirth or antenatal care. Those countries have maternal mortality rates of approximately 350 per 100,000 women. A total of 99% of maternal deaths occur in the developing world.

We have been tremendously well served by the attendance today of Professor Malone and Dr. Mahony. Their evidence, candour and professionalism in their work deserves our praise. Deputy Mattie McGrath made a glib comment about what the Rotunda Hospital is doing wrong. While I agree with Senator Mullen that we should not allow third parties to be named here, equally we should not allow members of the committee to make glib one-line statements or to quote reports like that from Duke University, which is open to all kinds of interpretation when it comes to data collection, as Professor Malone quite rightly pointed out. If we are going to use statistics and reports then there is a duty on all of us, whatever our position on the matter, to do so in a manner that is honest and credible. We can all use statistics to bolster any argument we want.

I will just say a few words seeing as I have been drawn into this. I have no problem with an analysis of the quality of evidence being produced by Deputy McGrath but I object to the motivations of any member-----

I am not questioning his motivation.

Words such as glib are unhelpful. Senator Buttimer has a point but is being unfair-----


I am fairly balanced in my approach.

I point out to Senator Buttimer that we have been here since 1 o'clock today.

I have been here too.

I do not wish to get into any arguments at this point in the day. The witnesses have given up their time and we want to get some information from them. If we want to pick up this sort of conversation then we can do so on another day.

What I wanted to say, to assist Senator Mullen and the members of the committee, is that the people who work in the Rotunda and in the other maternity units are doing exceptional work. We should not allow them to be portrayed otherwise on the record of this committee. I previously chaired the Joint Oireachtas Committee on Health and Children and I must say that Dr. Mahony is a credible and excellent witness. On the six days of hearings that she appeared before that committee to discuss the Protection of Life During Pregnancy Bill, she was an extraordinary witness and never controversial or unhelpful to the committee or to the preparation of that legislation.

Dr. Mahony made a very good point about vulnerable women. Part of what we must do as a committee, even if we do nothing else, is to show particular support to the young vulnerable women to whom Dr. Mahony and others referred. What pathways of care and support can we offer there? What should we be doing outside of the work here on the eighth amendment? We can all agree that Ireland is a very safe place in which to have a baby. Professor Malone referred in the last paragraph of his presentation to the impact on resources in our maternity services if we were to change our current position. Could Professor Malone elaborate on this?

Dr. Rhona Mahony

The Senator asked a good question on what else we can do for young and vulnerable women in society. We must start at the beginning. If we are going to equip young men and women for adulthood then we really need to provide them with good sex education. This should begin in school and continue throughout their lives. Sometimes the programmes in our schools can be quite limited, however. It is not just a matter of learning the biology of how a woman gets pregnant but also all of the other issues surrounding that, such as alcohol and drug use, for example. That is very important. It is also important that we have supports there for young women who do find themselves pregnant. There needs to be good support and good counselling and they need to be able to get access to care. In our hospitals, for example, we have adolescent clinics in order that young girls can, first of all, meet one other, and second, not go through a system with much older women causing them to feel even more excluded. Nor is this just a matter for women. We also need to equip men to deal with human sexuality. I think Senator Buttimer has asked a great question and that as a society, we need to work really hard with young boys and girls in order that they can have respectful, healthy and responsible intimate relationships. This means that if people do not want to get pregnant in the first place they do not become pregnant, and that if they eventually do become pregnant they are healthy and able to deal with the pregnancy. I think that there is a lot more that we can do in this area.

Professor Fergal Malone

We could talk for a long time about the resource issues. Personnel is clearly one. We are still very much in deficit when it comes to operating theatre nurses and midwives, although that situation is improving.

It is great that the National Maternity Hospital will be moving to a new space in the near future and Cork University Maternity Hospital has a beautiful new building in recent years but the physical structure of many other hospitals is not conducive to providing the best possible care for patients. One could have a situation where a patient recovering from a surgical management of a miscarriage - and in the future that might be recovery from a surgical management of termination of pregnancy - wakes up from anaesthesia in a recovery room separated from a woman recovering from a caesarean section holding a crying baby. That is an appalling vista but those are the physical structures of some of our hospitals currently. The resources we need are not only in the area of personnel; we need all 19 maternity units to have as good a physical construct as Cork University Maternity Hospital or the new National Maternity Hospital. They are the standard we should aim for. There is a very significant capital infrastructural requirement.

Dr. Rhona Mahony

Infrastructure in obstetrics really matters because we need to transfer patients really quickly from one unit to another. In the design of the new hospital in Elm Park, a big part of that was the clinical input to ensure that when a woman arrives into the hospital, she can get to the labour ward quickly, to theatre quickly and her baby can get to the neonatal unit quickly. There is an idea of a hot core where patients who require it can be transferred really quickly throughout a building. Infrastructure is very important in the provision of obstetric care.

I sincerely thank Dr. Mahony and Professor Malone for their very helpful and insightful contributions and for answering all members' questions. We are very appreciative of their time as we know they are very busy people.

There are Standing Orders, rules and precedents when it comes to motions and voting in committee and I want to take some advice on, or at least be apprised of them, before tomorrow's meeting. I propose we revisit that issue tomorrow at 2 p.m.

The joint committee adjourned at 7.13 p.m. until 2 p.m. on Thursday, 12 October 2017.