Joint Committee on the Eighth Amendment of the Constitution díospóireacht

Risks to Health, Including Physical Health, of Pregnant Women: Professor Sabaratnam Arulkumaran, Dr. Peter Boylan and Dr. Meabh Ní Bhuinneáin

Chairman

Before I introduce our witnesses today, at the request of the broadcasting and recording services, members and visitors in the Public Gallery are requested to ensure that their phones are turned off completely or at least put on airplane mode for the duration of this meeting. I want to reiterate the fact that it causes severe interference. If RTÉ or other broadcasters try to show clips, devices really impair the quality of the material. I ask everyone to please co-operate on that matter.

It is very warm in this committee room of which our guests in the Gallery will be aware. I have complained about the heat and I have been told that the OPW has been called to sort out the issue. We will have to arrange to change rooms if this situation continues because we will probably meet here for six or seven hours. It is very difficult to concentrate on proceedings when one is as warm as we are at the moment.

I would like to extend, on behalf of the committee, a warm welcome to our witnesses - warm being the operative word - for this afternoon's meeting. I welcome Professor Sabaratnam Arulkumaran, President-Elect of the International Federation of Obstetrics and Gynaecology and author of the report on the death of Savita Halappanavar. I also welcome Dr. Peter Boylan, Chair, Institute of Obstetricians and Gynaecologists, and Dr. Meabh Ní Bhuinneáin, obstetrician and gynaecologist, Mayo University Hospital, Castlebar, County Mayo. I do not know if she is a Mayo woman but she is in the right county. All of the witnesses are very welcome to this afternoon's meeting.

Before we commence formal proceedings, and at the risk of boring some members, I must go through the formalities. I wish to advise the witnesses about privilege. By virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to this committee. However, if they are directed by the committee to cease giving evidence on a particular matter and continue to so do, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable.

Members are reminded of the long-standing ruling of the Chair to the effect that they should not comment on, criticise or make charges against a person outside the House or an official either by name or in such a way as to make him or her identifiable.

I invite Professor Arulkumaran to make his presentation.

Professor Sabaratnam Arulkumaran

I wish to express, to Senator Noone and respected members of the Oireachtas Joint Committee on the Eighth Amendment of the Constitution, my sincere thanks for providing me the opportunity to give evidence on the important issue of reviewing the eighth amendment of the Constitution of the Republic of Ireland.

The issue is linked to the sexual and reproductive health and rights of women, the subject on which I have worked for decades as a women's health physician and in my capacity as past president of the Royal College of Obstetricians and Gynaecologists, the British Medical Association and of the International Federation of Gynecology and Obstetrics.

For today, I was specifically asked to focus on the particular concern to the committee which is the issue of the risk to the health of the mother including her physical health, which the Citizens' Assembly refers to in its recommendations 3, 5, 6 and 8. Please permit me to start with some general remarks that will be followed by my answers to the specific issues.

First, I congratulate and praise the maternity care in the Republic of Ireland that has had a very low maternal mortality ratio for years and is ranked sixth in the whole world, as shown in a graph that I have included in my presentation to the committee.

Details of these few deaths are always analysed by the Irish obstetricians. A confidential inquiry into maternal deaths in Ireland indicates nearly half are due to indirect deaths, not related to pregnancy but due to cardiac and psychiatric conditions and so forth. This is of some relevance to the issue under discussion. The detailed report on the confidential inquiries is included and referenced in my statement.

I greatly appreciate the first report and recommendations of the Citizens' Assembly on the eighth amendment of the Constitution, published on 29 June 2017. I commend the Citizens' Assembly on its work. The report is an impressive achievement by people who are not health care specialists or experts, but spent five weekends considering the issues. The members of the Citizens' Assembly voted on their recommendations for access to abortion for certain medical and other conditions. Members are, of course, familiar with the results of the ballots and these can be viewed in the report.

I would like members to consider the opposite side of the coin and if the same questions were asked such as: "Would you send the women who procured abortion for these reasons to prison?" A research project in Brazil led by the eminent obstetrician and gynaecologist, Professor Aníbal Faúndes, surveyed 1,660 civil servants and 874 medical students. They were asked two different questions: first, under what circumstances should abortion be allowed under law; and, second, if they agreed that women who had abortions outside the law should be imprisoned. The research concluded that Brazilians have different views on when abortion should be legal, but most do not agree with imprisoning women for abortion. Hence I urge parliamentarians, the newspapers and the public to take that into consideration and ask the question as to whether they would wish to imprison women who procure abortion. A law that allows abortion for only certain minimum grounds mandates the imprisonment of women who have abortions under all other grounds. I think members would find that this is not what the public wants, neither in law nor in practice.

I shall now give my views on the specific health issues that were raised in the Citizens' Assembly report and other health issues that were not raised but are of relevance to the eighth amendment of the Constitution. First, abortion is life saving in certain health conditions, for example, a mother with chorioamnionitis and severe sepsis, pre-existing severe heart disease, and poor mental health and a threat to commit suicide. There are examples of such incidents from the Republic of Ireland. Deaths from these conditions occur due to the difficulty in assessing that the seriousness of the condition meets the legal criteria of "real and substantial risk" that can only be averted by ending the pregnancy, and the fear of legal punishment that prevents a doctor from taking a firm and early decision.

Abortion in certain health conditions will avoid deterioration of health, for example, cardiac, renal, and neurological conditions. We could formulate a list of conditions but we will not be able to cover all the different conditions and combinations of conditions that we encounter as clinicians. Each mother needs to be individually assessed as to whether the condition is serious enough to terminate a pregnancy. Such lists are used in certain countries where restrictive abortion laws operate. However, mothers slip through the net and end up with worse organ damage. A list of the medical conditions that are considered serious enough to terminate a pregnancy in Peru include hyperemesis gravidarum refractory to treatment with severe hepatic and-or renal impairment; malignant neoplasm requiring surgical treatment, radiotherapy and-or chemotherapy; functional class III or IV cardiac failure; severe chronic arterial hypertension and evidence of organ damage; systemic lupus erythematosus with severe renal damage refractory to treatment; advanced diabetes mellitus with vital organ damage; and severe respiratory failure demonstrated by certain parameters. The Peruvian document is included in the references.

The errors due to conservative management of continuation of pregnancy compromise the mother's health with further deterioration of organ function that leads to shorter life span and at times death. Such incidents are greater in the countries with restrictive abortion laws and are due to fears by the doctors of facing legal action. An article showing an example of such deterioration involving a cardiac condition is included in the references.

Abortion under optimal conditions has less maternal mortality in developed countries compared with continuation of pregnancy. It is 0.7 per 100,0000 with safe abortion care compared with ten per 100,0000 with continuation of pregnancy. These are due to life threatening complications such as thromboembolism, hypertensive disease, postpartum haemorrhage, amniotic fluid embolism, and so forth as referenced in WHO document.

In the United Kingdom, approximately 190,000 abortions are carried out each year and there were only two recorded maternal deaths in the five years from 2012 to 2016. The statistics of UK abortions are referenced. The clear majority of abortions were done under clause C, that is, that "the pregnancy has not exceeded its twenty-fourth week and that the continuance of the pregnancy would involve risks greater than if the pregnancy were terminated" of injury to the physical or mental health of the pregnant woman mainly on grounds of further deterioration of mental health.

Abortion is not associated with physical or mental health hazards to the mother and it has no impact on future pregnancies. This has been made clear by the statement of the Royal College of Obstetricians and Gynaecologists and is included in appendix 1.

Abortion should be permitted for lethal foetal malformation and severe congenital malformation that may have a major impact on life. This is also the position of the Royal College of Obstetricians and Gynaecologist and is included in appendix 2.

Safe abortion care should be considered as a public health and human rights issue. Despite good contraceptive coverage, about 10% of women get pregnant and seek abortion. In countries where abortion is legalised, the total abortion rates and maternal mortality have declined due to safe post-abortion care and post-abortion contraception.

Making abortion illegal has not stopped illegal abortion for centuries and in different countries. It increases maternal mortality, and this is referenced. About 4,800 women in Ireland have their abortions done in the United Kingdom. These are the reduced figures as the numbers have reduced by 20% in the past year or so due to availability of medication by post for self-procuring abortion. These have their own complications.

Abortion is a sexual and reproductive rights issue and the decision should be made by individual women after adequate information is given. If abortion is not made legal, it will promote illegal abortion. Those women with influence and financial resources will get it performed in a safe environment. Those who are poor with less influence will resort to unsafe abortions. This would be a social injustice.

I shall conclude with a few extracts from some of the world bodies. The WHO states that "abortions and the high maternal and child mortality rates constitute a serious public health problem in many countries". It continues:

Criminal laws penalising and restricting induced abortion are the paradigmatic examples of impermissible barriers to the realisation of women's right to health and must be eliminated. These laws infringe women's dignity and autonomy by severely restricting decision-making by women in respect of their sexual and reproductive health.

The report of the UN special rapporteur on the right to health to the UN General Assembly in 2011 stated: "Certain criminal laws effectively shift the burden of realising the right to health away from States onto pregnant women, punishing women for the lack of effective provision of health-care goods, services and education by the Government."

Ireland can and should provide first class sexual and reproductive health based on rights and public health perspectives. There are minimal ill effects to health with a well-informed safe abortion. This is from the Royal College of Obstetricians and Gynaecologists, appendix 4. Health advantages of avoiding or not having unwanted pregnancy need to be considered in addition to specific socio-cultural issues faced by the women.

The excellent maternal mortality rates in Ireland as number six in the world may become 20th or 40th in the world if legal access to abortion is denied to the 4,800 women who may not be able to go to the United Kingdom, but may procure illegal abortions. At any cost, we must avoid having illegal abortion. I thank the Chairman and members for considering my submission statement.

Chairman

I thank Professor Arulkumaran for his opening statement. I call Dr. Boylan.

Dr. Peter Boylan

I thank the Chairman, Senator Noone, and members of the committee for the invitation to appear here today. My opening statement is a summary of the longer position paper, which I also supplied to the committee. The content of this statement is rooted in over four decades of the practising of obstetrics, caring for women in Ireland, London and the United States.

I hope to assist the committee in its deliberations.

I am currently chairman of the Institute of Obstetricians and Gynaecologists of Ireland. I was master of the National Maternity Hospital from 1991 to 1997 and clinical director from 2008-2014. In 2012-13, I served as a member of the committee of independent experts which advised the Government on the implementation of the European Court of Human Rights judgment in respect of the X case. The outcome was the Protection of Life During Pregnancy Act 2013. In 2013 I was the independent expert witness for the coroner in the inquest into the death of Savita Halappanavar. In 2014 I was an expert witness for the family in the case of Miss P v HSE in the High Court.

The Institute of Obstetricians and Gynaecologists of Ireland has not been asked to provide a position paper. However, in preparation for this hearing, I canvassed the opinions of members and have incorporated feedback received into this statement.

When put to the vote, the majority of the Citizens’ Assembly voted against maintaining the status quo of the eighth amendment. By a substantial majority the assembly voted in favour of legalising termination when a woman’s life or health is at risk, when pregnancy follows rape, in cases of foetal abnormality, for socioeconomic reasons, or without restriction.

The assembly also made five ancillary recommendations, including those relating to improvements in sexual health and relationship education; access to early scanning and testing in pregnancy; counselling services; and that consideration should be given to who will fund and carry out terminations. I support the ancillary recommendations without reservation. On the fifth ancillary recommendation, it is my opinion that if termination is legalised it should be funded by the State, rather than delegated to private agencies. All terminations should be medically supervised. Medical personnel with a conscientious objection should be excused from involvement.

Article 40.3.3° gives rise to significant difficulties for doctors practising in Ireland and has caused grave harm to women, including death. The two outstanding examples of which I have direct personal experience are the death of Savita Halappanavar in 2012 and the case of Miss P in December 2014. These are only two examples of cases where doctors in Ireland continue to be put in the inappropriate position of having to interpret the Constitution in the course of caring for sick women. Medical personnel have no difficulties in obeying clear legislation and medical regulations, but we are not trained for the complexities of constitutional interpretation, nor should we reasonably be expected to be.

The eighth amendment has given rise to legal cases including the X case; the C case; A, B and C; D v Ireland; the Miss D case; A, B, and C v Ireland; Miss Y; Mellet v Ireland; and Whelan v Ireland. These are the difficult and painful cases of Irish women and girls who have had to resort to stressful legal processes in the absence of comprehensive legislation on abortion. If the eighth amendment is not repealed, this list will continue to grow and Ireland will continue to be censured by international bodies such as the European Court of Human Rights and the United Nations.

Currently, termination of pregnancy on grounds other than risk to the life of the woman is subject to criminal prosecution with the penalty of imprisonment for up to 14 years for women and their doctors, while simultaneously the 13th amendment provides constitutional protection for women to travel to obtain a termination outside the State and the 14th amendment protects the right to access information necessary to achieve this. This is profoundly hypocritical. Our Constitution enshrines a woman’s right to commit an act which is a criminal offence in her own country, as long as it is committed outside the State. By any yardstick this is a bizarre situation. Testimony from numerous Irish women demonstrates the pain and stress they have undergone and continue to experience as a result of Ireland’s ongoing failure to legislate comprehensively. Members of the committee should not underestimate the anger felt by women who have to travel abroad for termination of pregnancy.

In my longer position paper, I have included an analysis of EU legislation. Some 99% of women in the EU live in countries where their legislatures have grasped the nettle of legislating for termination of pregnancy. No doubt many other EU countries have had difficulties with the subject, given their own religious, political and social histories, but their legislators have had the will to deal with the issue. The Irish position remains deeply anomalous and obviously politically contentious. In the matter of women’s reproductive health, we remain outliers in a tiny minority in Europe.

Legal provision in the EU for termination of pregnancy is as follows. In the case of risk to the life of the mother it is provided for in all countries except Malta. In the case of risk to the health of the mother it is provided for in all countries except Malta and Ireland. Termination for pregnancy as a consequence of rape is available in all countries except Malta and Ireland. Termination in the case of foetal abnormality is available in all countries except Malta and Ireland. Termination for medical reasons beyond 12 weeks, which varies by country, is available in all countries except Malta, Ireland and Poland to a varying degree.

I suggest that in 2017 the eighth amendment is unworkable. When it was enacted 34 years ago, neither the worldwide web nor the abortion pill had been invented. The committee heard evidence last week that the rate of women accessing the abortion pill from online service providers is increasing. In reality, there are many services that facilitate people living here with a means of securing delivery to a designated address, which means they access items such as abortion pills. While importation of these pills into Ireland is illegal, in another bizarre twist which mirrors the contortions of the Constitution, An Post offers customers a virtual UK address to use as their shipping address via the addresspal.ie service.

The genie is therefore out of the bottle in respect of online access to the abortion pill. The grave concern that we, doctors, have as a consequence of this reality is the potential for harm caused by the use of unregulated medication by Irish women and girls. I believe it is a matter of priority for the Oireachtas to address the reality of this situation.

The Citizens’ Assembly vote clearly recommends that the Oireachtas deal with the question of termination by legislation rather than through the Constitution. I entirely concur with this conclusion, but I would add that legislation needs to be supported by regulation with regard to clinics and hospitals, and by the Medical Council and An Bord Altranais.

The question of viability needs to be addressed in the practical implementation of the recommendations of the Citizens’ Assembly. In Ireland, viability is currently considered to occur at approximately 24 weeks' gestation. When obstetricians deliver a baby at the margins of viability, it is standard practice in this country to have a full neonatal team present at the birth to make an immediate assessment about viability and institute intensive care in every case where appropriate. I cannot envisage a scenario whereby any doctor in Ireland would support any proposal that termination of pregnancy would be contemplated beyond 23 weeks. I hope this is reassuring to the committee in respect of the uninformed discussion that regrettably occurs in respect of so-called "late-term abortion".

Medical termination is performed by the administration of two medications. Mifepristone blocks the action of progesterone, a hormone necessary to support pregnancy before the placenta develops and misoprostol makes the uterus contract. Taken in combination two or three days apart, these tablets have a success rate greater than 90% if taken in the first trimester, preferably before ten weeks. The first tablet is taken in a clinic or doctor's surgery and the second is taken at home. The woman then experiences symptoms the same as a miscarriage. The rate of side effects is extremely low.

For pregnancies of later gestation the procedure needs to take place in the hospital setting and will require more medication over a longer period of time. If the Oireachtas legislates to allow termination, it is likely that later terminations will only be legalised for reasons other than socioeconomic or without restriction. Surgical termination is where the contents of the uterus are removed either by suction or curettage following dilatation of the cervix.

The Protection of Life During Pregnancy Act 2013 deals with the question of termination of pregnancy in circumstances where there is a threat to the life of the mother, including by suicide. In the years in which it has been in force there have been approximately 25 terminations each year. A major difficulty with this Act is that it is entirely the responsibility of doctors to determine how close to death, or how sick, a woman must be before legal termination can be performed. The woman herself has no input into the decision, other than the option of refusing termination and placing her life at risk. Doctors are subject to criminal prosecution if it can be established that they acted in bad faith in recommending a termination, even if the woman herself is happy with the decision.

Serious risk to the physical or mental health of the woman overlaps with threat to the life of the mother in so far as a risk to health may develop into a risk to life. Under current legislation doctors have to make judgment calls as to when a risk to health becomes a risk to life. If the judgment is wrong, either the mother will die or the doctor will be guilty of committing a criminal offence.

Risk to the health of the mother, either physical or mental, raises the important question of how different people deal with risk. Some women, perhaps those expecting a much longed-for first baby, are willing to accept any risk in order to have a baby, while for others, perhaps those with small children at home, the deterioration in their health represents an unacceptable risk. In these complex circumstances, a decision to terminate is best left to the woman and her doctor.

Pregnancy as a result of rape could be dealt with in a straightforward way by legislating for the legal prescription of the abortion pill which I have previously described. Pregnancy tests are now so sensitive that they are positive just before a missed period and so the pills would be 99% successful if taken within the first eight weeks.

There is no diagnostic test to confirm rape, so I strongly recommend that a woman who has undergone the trauma of rape should not be forced to "prove" rape if she chooses to terminate a resulting pregnancy. Women should be taken at their word - hardly a revolutionary concept.

Foetal abnormality likely to result in death either before or soon after birth of the baby was covered in detail in evidence last week from the masters of the Rotunda and the National Maternity Hospital. They both outlined the clinical risks associated with current legislation. For those who continue with the pregnancy, hospice care for the newborn with little or no chance of survival outside the womb has, in my experience, been a long-standing practice in this country in our hospitals. It is simply incorrect to state that this care is not available. I have considerable personal experience of couples that have had the misfortune of receiving diagnoses of foetal abnormalities. In some cases, the parents have chosen to continue with the pregnancy and have been much comforted by having some time, however brief, with their baby. In other cases, couples have been unable to continue with the pregnancy and have travelled abroad for termination. However, what is not so well understood is that some couples experience a diagnosis of foetal abnormality on subsequent pregnancies - in other words, twice or more. My experience has been that in the vast majority of these sad cases, on the second or subsequent occasions the couples choose termination, even if they had elected to continue with the pregnancy on the first occasion. I also have experience of couples who, prior to screening for an abnormality, declare confidently that they would not seek termination in the event of a serious abnormality being diagnosed, only to change their minds when confronted with the reality of serious foetal abnormality. I think most people in Ireland would sympathise with this.

Significant foetal abnormality unlikely to result in death before or shortly after birth raises more difficult questions. In particular, how can we define "significant" abnormality? Antenatal diagnosis, including ultrasound, genetic testing and magnetic resonance imaging, MRI, is now much more sophisticated than in the past. When the eighth amendment was enacted, this level of diagnostic capability was not available. The "significance" of the abnormality may depend on the extent of the disability and-or parents' ability to cope with the consequences. In some conditions, particularly genetic ones, there is a wide spectrum of severity. Parents, in consultation with their doctor, are the people best able to make decisions in their individual circumstances. Diagnosis of genetic abnormalities can now be made before 12 weeks' gestation by a blood test, confirmed by either amniocentesis or chorionic villus sampling.

I now come to termination for socio-economic reasons, or without restriction. As I have said, throughout the European Union, 99% of women have access to termination of pregnancy without restriction up to ten weeks of pregnancy. The remaining 1% are those women who live in either Ireland or Malta. Of course, the majority of these women live in Ireland. The method used in these cases is medication, which, as we know, is increasingly used by women in Ireland. Of the citizens who voted for termination without restriction, 92% voted to limit gestation to 12 weeks.

It is well documented that in countries where abortion is banned, the rate of women dying remains high. Approximately 70,000 women die each year from complications relating to unsafe abortion. The committee heard testimony last week from Dr. Abigail Aiken that Irish women today are attempting self-abortion with potentially fatal consequences. It is equally well documented that countries with liberal laws and easy access to contraception have lower rates of abortion than those with restrictive laws. Women in Ireland with financial resources have access to termination of pregnancy, primarily in the UK. However, women who are poor, in the care of the State or refugees, for example, do not have such access. The thirteenth and fourteenth amendments to the Constitution are of no assistance to these women. Without access to abortion in the UK, it is inevitable that Ireland would have an epidemic of illegal abortions and a massive increase in maternal mortality. If Ireland were to enact legislation in line with EU consensus, including termination without restriction up to ten weeks, our law would be among the most conservative in Europe but would deal with the vast majority of circumstances in which women currently access services outside the State. I believe that the forthcoming referendum on the eighth amendment should put a simple binary question to the electorate for or against repeal. Legislation is the responsibility of the Oireachtas, not the people. On repeal of the eighth amendment, Irish law on termination of pregnancy would continue to be governed by the Protection of Life During Pregnancy Act and there would be no legislative vacuum pending further legislation. In the meantime, women in Ireland will continue to access services in the UK or elsewhere in Europe, or access abortion pills illegally.

Chairman

I thank Dr. Boylan for his opening statement. Finally, I call on Dr. Ní Bhuinneáin to make her presentation.

Dr. Meabh Ní Bhuinneáin

On behalf of the Institute of Obstetricians and Gynaecologists, I thank the Chairman and members for the invitation to present. I am a practising consultant obstetrician and gynaecologist in Mayo University Hospital, Castlebar. I am national speciality director for basic speciality postgraduate training in obstetrics and gynaecology in the institute. I am dean of medical education at Mayo Medical Academy, Castlebar, a teaching academy of the School of Medicine, NUI Galway. My clinical and teaching practice encompasses general obstetrics and gynaecology in the rural, non-tertiary setting in Ireland and an interest in global maternal-reproductive health and development.

As requested in the invitation to today's proceedings, the comments I will make refer to the issues that may arise if the recommendations of the Citizens' Assembly on the eighth amendment are adopted in part or in whole by Irish society. My status is as a witness from a professional body whose membership replicates the diverse views of Irish society. The institute does not have, nor should it purport to have, a common stance. These comments are my opinions, except where otherwise noted, informed by the views of members who wished to contribute and wished to be clear about the status of the presenters today. The complex and often conflicting elements that inform discussions on termination of pregnancy cannot be disaggregated, although they need to be studied as separate entities for the sequential programme of work that this committee is undertaking with diligence. The work of this committee on the matter of the eighth amendment requires consideration of the guiding principles of ethics and human rights balanced by the right to national and individual self-determination.

Globally, maternal-reproductive health outcomes are one measure of effective civil society and government partnership. In high-income settings, sub-national adverse outcomes are often concealed if the metrics used are the rare frequency of mortality over the common frequency of physical and psychological morbidity. Globally, restrictive termination of pregnancy legislation contributes to maternal mortality and significant morbidity disproportionately in vulnerable women and girls, as supported by the witnesses from the World Health Organization, WHO, last week and today's witnesses. While I speak as a health professional in active clinical practice, I wish to re-emphasise the inter-sectoral and social determinants on quality reproductive health outcome as included in the first two ancillary recommendations of the Citizens' Assembly. Outside the scope of today's meeting, Members of the Oireachtas may consider their ability to influence the wider development of reproductive health care when deliberating over connected interventions that are delivered in the sectors of education, social welfare, youth development and finance.

If the introduction of a woman and girl centred safe termination service is the desire of the Irish electorate, it should be considered as just one element of a comprehensive reproductive health programme. Engagement with women and girls and men and boys is required to develop formal and informal reproductive health education programmes, strengthen peer education as a delivery method for life skills learning and develop responsive, acceptable, affordable and locally accessible services while also facilitating the bypassing of local services, especially in rural areas, where anonymity and distance from home may be preferred. Delays and barriers in access to safe reproductive health services, including termination of pregnancy, are influenced by distance, institutional reception, cost and bypass behaviours.

Health care workers in women's health in Ireland are guided by the legislative framework of the country, the professional standards of the registration authorities, their professional bodies and their personal value systems, whether conscious or unconscious. Obstetricians and gynaecologists in Ireland to date, whether specialists or postgraduate trainees, have not been systematically studied to explore their position on the specific items on which the members of the Citizens' Assembly have been balloted. The process to secure professional readiness to respond to possible legislative change has not yet been determined. It is not known if the views of the women's health professionals will reflect the results of the Citizens' Assembly ballot. Many clinical providers in Ireland in women's health have trained or completed some part of their training in other countries where termination of pregnancy is lawful. Some of those providers would have already explored their personal ethical decision-making pathways. For some, new legislation would involve the unlearning of restrictive practices in providing health care in Ireland at this time. However, for the majority of clinical providers in this country, the possible enactment of lawful termination of pregnancy in Ireland may lead to individual professional moral distress for the first time.

Training needs also include cultural and diversity competence, unconscious bias awareness and the development of a national framework for ethical decision-making. Care, support and sensitive leadership within the professions to deliver a new service following ethical decision-making is required. Societal care, support and avoidance of alienation of health care workers during such transformative change is also required.

Regarding health systems, if in due course there is legislative change, the new system would be commissioned and provided. Regulatory codes of practice would be revised and the professional bodies would review their competence standards, training curricula and assessment tools. Quality assurance and suitable designation of centres that provide termination of pregnancy would be required. Centres may include certain primary care services, family planning and sexual health clinics, infectious disease clinics, maternity units, and general hospitals with gynaecology and sexual assault treatment units. The logistical challenges are those faced in the development of any new health service. The process would involve a multi-dimensional approach, including biomedical health system strengthening, informal health system strengthening, and engagement with women and families in addition to the actual service development.

The skill set for the medical and safe surgical procedures in relation to termination of pregnancy already exist in obstetrics and gynaecology and women’s health services in Ireland. Some exist in the primary care setting as discussed by the Irish College of General Practitioners, ICGP, witnesses last week and some exist in the early pregnancy care units and the tertiary maternal foetal medicine units throughout the country. The training and service expansion needs are in the domains of professionalism, communication, inter-sectoral and inter-professional team work.

Conscientious objection would be facilitated for all cadres of health care staff. This may result in logistical problems in the smaller rural centres, especially as there are already existing rota gaps, a mismatch in the urban-rural distribution of doctors, nurses and midwives, and a dependency on agency workers. One third of obstetricians, gynaecologists and midwives in Ireland work in the smaller centres with significant dependence on international medical graduates to provide specialist obstetrics and gynaecology services. There is the mixed challenge of providing continuity of services with unstable manpower in some disciplines and also overly stable workforce in other disciplines, where the introduction of change is less common. Of importance for the smaller centres is the agreed tertiary pathways for complex care with agreed automatic acceptance protocols for maternal transfer, whether it is an emergency or elective case in nature. Conscientious objection may also compound the problems of recruitment to the relevant disciplines, the attrition of trainees and retention of older providers in the specialties during a period of transformative change. We do not yet know the unknowns in this subject area.

There has been significant initiation of organisational development in women and infants' programming in Ireland at national level in the past decade, sadly in many instances in response to unacceptable adverse outcomes. Women’s advocacy and advisory contributions, national governance, regulatory standards, guideline development and implementation, hospital group structure, managed clinical networks, HSE clinical programmes, primary care teams, the frameworks for quality and the National Office of Clinical Audit have contributed to progressive system strengthening in both urban and rural women’s health care provision. All these developments provide a degree of organisational preparedness for the introduction of an expanded reproductive health service, if required to do so by the Irish people. However, by international and OECD standards, the women’s health service continues to be considerably under-resourced, fragmented and, in public opinion, as surveyed in the preparation of the first National Maternity Strategy 2016, is not yet considered to be woman and family centred or woman led.

My final comments reflect individual notes from institute members. In other jurisdictions, initial restrictive termination law has evolved into more liberal practice. Members have noted that overly prescriptive categorisation of foetal anomaly may prevent the evolution of matching options with health technology advancement. They recommend that the detail is provided for in the initial legislation and subsequent regulation rather than by constitutional amendment. Some gynaecologists have expressed potential personal moral distress at the dual challenge of providing extraordinary life-saving interventions for one foetus or infant at borderline viability while also providing foeticide for a potentially normal foetus at the same gestation. Those members who wished to contribute gave general support for the provision of termination for fatal foetal anomalies. Some members view the current law as excessively restrictive for crisis pregnancy. I thanks the committee for the opportunity to present today.

Deputy Billy Kelleher took the Chair

Acting Chairman (Deputy Billy Kelleher)

I thank Dr. Ní Bhuinneáin. In view of the fact that there is a vote in the Seanad, the next speakers have to go so Deputy McGrath is next up.

Deputy Mattie McGrath

I have to speak in the Chamber. There are other speakers after me.

Deputy Louise O'Reilly

I can substitute for Senator Gavan if that is agreed.

Acting Chairman (Deputy Billy Kelleher)

That is fine. I call Deputy Louise O'Reilly.

Deputy Louise O'Reilly

I thank the Chairman and the witnesses. I am substituting for my colleague, Senator Paul Gavan, who had to leave for a vote in the Seanad.

I am interested in the three witnesses' views on the issue of risk. Is there such a thing as a gradation of risk such as serious risk and grave risk? Those are the types of terminologies we are using and indeed that the Citizens' Assembly used, but I am not sure if they are legal terminologies or if they translate easily or at all into a medical setting. If we are going to have a discussion about that, we should try to guide ourselves towards being helpful to the medical practitioners who ultimately are going to be at the business end of the results as it were. Could the witnesses let us know their views in relation to risk?

Professor Arulkumaran said there is an immediate and urgent requirement for a clear statement of the legal context in which clinical professional judgment can be exercised in the best medical welfare and interests of patients. Could Professor Arulkumaran explain to us why and how the team reached that conclusion and how that can best be implemented through legislation, regulations and guidelines?

My final question is to Dr. Boylan and Dr. Ní Bhuinneáin. It relates to the Irish system as it currently stands, its resources and personnel. In the event of a repeal of the eighth amendment and the provision, in circumstances however limited or otherwise they may be, of wider availability of access for woman to abortion health care, do we have the personnel? Do they need to be trained? In particular, will there be a rural and an urban split? There is clearly in operation somewhat of a postcode lottery with regard to access to some maternity services. We have discussed this at the health committee. Is it the witnesses' contention that we would need to see significant investment in capital or in people? Do we have the buildings, and we just need to put the people in them? Do we have the people and do they need additional training? How close would we be to implementing a more liberalised regime?

Deputy Hildegarde Naughton took the Chair.

Acting Chairman (Deputy Hildegarde Naughton)

Who would like to come in first? I call Professor Arulkumaran.

Professor Sabaratnam Arulkumaran

I can answer the first question. I could not follow the second question, so could the Deputy kindly repeat it for me?

Deputy Louise O'Reilly

I apologise - I am reading from my colleague's notes.

Acting Chairman (Deputy Hildegarde Naughton)

Is there another answer that the witness would like to give first?

Professor Sabaratnam Arulkumaran

Deputy Louise O'Reilly

Is the necessary physical infrastructure in place in rural Ireland, given we know there is a difference there? Would we need more capital investment and do we have the personnel right across the country, as opposed to just in certain designated centres?

Dr. Meabh Ní Bhuinneáin

The physical infrastructure is quite variable across the country and it is determined very much by the woman-centred and girl-centred care. There is usually separation of early pregnancy services and termination services from ongoing services where women are attending an antenatal clinic and presenting with intended pregnancy and continuing pregnancy. This is not the same in all European countries. In hospital visits in many other jurisdictions, one sees signposting for all women's health services in the same area. In Ireland, traditionally, we divide services by times of day, so we are using multi-function areas that may be for one function early in the morning and another function later in the day. This is not satisfactory to the women and girls using our service and this comes through in patient surveys and in the advisory groups with regard to patient and family engagement in the general hospital setting.

In the women's hospital settings in Ireland, greater attention has obviously been paid to the reception of women and their families in regard to pregnancy. In the general hospital setting, it is harder to differentiate between reception for those coming with physiological problems and socially determined health problems as opposed to those coming with pathology and disease.

Acting Chairman (Deputy Hildegarde Naughton)

I call Senator Mullen.

Senator Rónán Mullen

I would like to start by asking each of the speakers about their own personal ethical position on abortion. In other words, do they believe that at any stage the unborn baby has a right to be protected, independently of the question of whether his or her continued existence is desired? In what cases do they believe the baby has a right to be protected?

Acting Chairman (Deputy Hildegarde Naughton)

Does the Senator have further questions?

Senator Rónán Mullen

I will take them one by one.

Acting Chairman (Deputy Hildegarde Naughton)

Do any of the witnesses wish to begin?

Professor Sabaratnam Arulkumaran

I have a very simple response. It is not about the issue of protection of the foetus per se. We have to really balance between the foetal and the maternal side. Let us suppose that for a condition very early on in pregnancy, in assessing a situation, medical or otherwise, if I believe that if I do not do the termination, she is going to go and procure an illegal termination and run into difficulties like that, I would take that responsibility and perform that abortion. However, if it is after foetal viability, then I will not go near the scene. I will assess the whole condition and do that.

This particular question about mortality, legality and ethical issues is asked of me from time to time. Everybody in this room is abortionist. Some support legal; those who do not support legal support illegal abortion. We are lucky in Ireland because they are able to go and get it done in England. Otherwise, can we imagine what will happen to the 4,800 women within Ireland? I would rest my case on that.

Dr. Peter Boylan

Again, it is important to take into consideration that this is not about the doctor; this is about the woman, her ongoing pregnancy and her views, which have to be taken into account. While we do not park our ethical beliefs at the door and we certainly carry them with us, we have to respect what the women's views are. I think it is true to say that there is a wide range of ethical views on the acceptance of abortion in different circumstances right across the board. For some people, it is totally unacceptable in any circumstances whatsoever, even if the woman is going to die. Others would have a much more liberal approach where they are happy to provide abortion services under any circumstances whatsoever, and there is everything in between.

It is not a question. This bears out my concern.

(Interruptions).

Chairman

Is this a point of order?

Senator Rónán Mullen

Yes, it is. I want to put on record that this further bears out my concern that there simply is not enough time available to examine carefully what witnesses are claiming, which makes this a really farcical process on a life or death issue. I want to put that on the public record.

Chairman

I note the Senator's comment and I addressed this earlier. We agreed on a timeframe for all members. I am trying my best, as Chair, to be fair to everybody. In fairness, every time the Senator gets a little more time than most people. That is all I have to say on the matter. I call Deputy Kelleher who has ten minutes in total.

Deputy Billy Kelleher

I welcome the witnesses. I have a number of questions. My first question is for Dr. Boylan. He said in his presentation, with regard to foetal abnormalities, that up to ten weeks, amniocentesis or chorionic villus testing-sampling could identify whether there is a genetic abnormality. How late in the gestation period would we have to allow for all testing to be done to identify any other forms of fatal foetal abnormality other than the genetic ones? Would we have to legislate for up to 22 weeks, 18 weeks or 16 weeks?

Dr. Peter Boylan

Senator Jerry Buttimer

I apologise to the witnesses for having to leave to go to the Seanad for a vote. I thank them for being here.

I address this question to all three witnesses. Based on Dr. Boylan's presentation in which he suggests the Eighth Amendment of the Constitution is unworkable in 2017, do the other witnesses agree with him? Will Dr. Boylan elaborate a bit more on that please?

Professor Sabaratnam Arulkumaran

The Senator is asking whether the eighth amendment is workable in 2017. Given the explanations as to how the system is working in the context of the amendment, where superficially everything is working, but underneath it is not working, then if it were working why should 4,800 women travel to another country to procure an abortion? In my view, things will have to change. I do not think the eighth amendment as it stands is good for the women in Ireland.

Dr. Meabh Ní Bhuinneáin

The wider interpretation of the question is whether society is different in 2017 from 1983. I believe human rights, autonomy of the woman and her considered right to self-determination is more apparent now than it was in 1983. I was not of age in 1983.

Societal change has happened in many different areas of sexual, reproductive and health issues in the past century. Society has struggled with each development in these areas. They are very emotive and our value system comes into play. It is not possible to prevent women from accessing safe abortion services in other jurisdictions. Is it acceptable in our society to know that we are not looking after our women and girls in this country at this time?

Dr. Peter Boylan

I clearly think it is not working. It has resulted in cases such as Savita Halappanavar, Miss P and the whole alphabet soup we have of women going to the European Court of Human Rights and the UN and so on. It is also not working because as I have said, the genie is out of the bottle, with the abortion pill which is freely available and can be accessed via post offices in this country. There are many anomalies. Time has moved on and the eighth amendment is no longer fit for purpose in 2017.

Senator Jerry Buttimer

In the closing paragraph of his presentation, Dr. Boylan speaks about how initial restrictive termination law has evolved into more liberal practise in other jurisdictions. Given that backdrop, and the commentary that the floodgates could open in other jurisdictions, as medical professionals what is their view of the situation?

Professor Sabaratnam Arulkumaran

Chairman

The Deputy spoke instead of Senator Gavan. Would he like to come in now in the Deputy's stead?

Senator Paul Gavan

Yes. I thank all three witnesses for their presentations. I am finding the testimony of the medical experts and professionals very powerful and telling because they are people who are dedicated to the care and health of others. They have a very clear message.

I want to ask a question about the thousands of women who travel each year to Britain for abortions. We know that because they have to travel it means the termination will be delayed by a number of weeks. Is the fact the terminations are delayed because the women have to travel a significant factor in terms of the health of those women? That question is open to any of the witnesses.

Dr. Meabh Ní Bhuinneáin

The delays in accessing termination services contribute to significant morbidity. Health, in its widest sense, is not just the absence of disease. The woman does not have to have a complication as a result of this delay. The issue is the physical, psychological and social well-being she no longer has during this delay. The delays are not just because she has to travel to another jurisdiction. As a result of the current stigmatisation of openly seeking termination services and because of the concern about host responsiveness, her decision-making is often delayed in the very beginning. That is the first delay. The second delay is when she gets into a track where she is receiving some degree of advice. Is it impartial? Is it coming from an informal system? Is it coming from systems that are driven for missionary or fiscal reasons or is it coming from an open, objective and balanced system? The third delay is in actually accessing the care when she gets there. We are starting to see, as the Senator is aware from the media, that the host nation does not always have the capacity to meet the needs of these women when they arrive. That national capacity of the UK to continue to provide for us is under re-examination.

Chairman

The question is open to all three witnesses.

Professor Sabaratnam Arulkumaran

As I mentioned earlier, if it is done early, it is a medical termination whereas when a woman goes late, it is a surgical termination. The complications are much greater with surgical termination. The second issue is they cannot have a medical termination in the UK because they go one day and have to travel back so they all end up in late surgical termination at 11 weeks or 12 weeks. If it is done in Ireland with the legislation, they could have a medical termination at seven or eight weeks with minimal complications, minimal blood loss and minimal chance of infection.

Chairman

Would Dr. Boylan like to add anything?

Dr. Peter Boylan

I have nothing else to add.

Senator Paul Gavan

I have one other question but if it has been asked already there is no need to answer it again. I had to leave for a vote in the Seanad and I apologise for that. Dr. Boylan was very clear in his presentation that we need a straight repeal. Why is he so adamant that it has to be a straight repeal as opposed to some of the other possibilities that are being mooted?

Dr. Peter Boylan

I do not think the Constitution is the place to regulate medical practice. It is too rigid and as we have seen with the eighth amendment, it creates endless problems. Legislation and regulation following that legislation is the way to deal with it.

Senator Paul Gavan

If we take some other route, for example, putting legislation into the Constitution or being specific about grounds, would it just bring us back to where we are?

Dr. Peter Boylan

I think it would be an absolute nightmare in the future, primarily for Irish women or women living in Ireland but also for the medical profession.

Chairman

Senator Ruane has six minutes.

Senator Lynn Ruane

I learn more every week I attend a committee meeting. We think we have our positions when we come in here but we realise how much we do not know. I thank the witnesses for their expertise. Some of my questions have been touched on, in particular by Senator Gavan's last question. I am conscious we are coming up to the anniversary of Savita Halappanavar's death. It is easy for us, as we are not her family, friends or people who knew her, to keep hearing her name. However, it is important to ask the question while being sensitive of the impact it could have for people who are watching proceedings. Dr. Boylan said that Savita would still be alive today if she had been given an abortion when she first requested it. This is contested in some quarters by those who claim she died as a result of sepsis due to an inevitable miscarriage. Perhaps my question is for Professor Arulkumaran and Dr. Boylan because they were aware of the case and involved in the inquest. Do they believe the presence of the Eighth Amendment of the Constitution cost Savita her life? There have been claims that the eighth amendment saves lives but we very rarely look at the lives it has cost.

My other question is to all three witnesses and is about the socioeconomic grounds. Sometimes it is seen as a ground in isolation. In women from low socioeconomic backgrounds there is an intrinsic link between their background and poor health. How can we begin to look at those two together instead of separately? There is a connection between socioeconomic status and the overall health and well-being of women from poorer socioeconomic backgrounds. When assessing the risk to health or life of a pregnant woman, are any social indicators taken into account in that assessment and, if not, should they be?

Professor Sabaratnam Arulkumaran

I will start with Savita's case. It was very clear to me during the inquiry that the thing preventing the physician from proceeding was the legal issue because she repeatedly said she was concerned about the legal issue. I will give a little bit of explanation. The mother was sick. There was no question about that. Even at the last minute they were using a hand probe to see whether the baby's heartbeat was present or not. Any junior doctor would have said it was a serious condition and they must terminate. They were just keeping her going because of the mere fact the heartbeat was there. The legislation played a major role in making a decision. Somebody else might say they would have done the termination much earlier. That is a personal interpretation. It is why things are made difficult because of the legislation.

With regard to the second question on the socioeconomic situation, one has to look at each individual mother's case separately. One mother might be a single mother and might have difficulty in managing or feeding the children. Another might have been using contraception or experiencing physical or other abuse by the husband. As medical physicians, we have to take the socioeconomic background into consideration when a mother makes a request.

Dr. Peter Boylan

Savita died from sepsis and septic shock. There is no question about that. There were deficiencies in her care. There is no question about that. However, had she had her pregnancy terminated when she asked for it in the first few days of admission, she would not have developed the sepsis because her uterus would have been empty. The unfortunate fact is that when the waters break the barrier to infection ascending from the outside into the womb is broken and so infection ascends into the womb and then there is a problem. If the womb is empty and the woman is delivered of her baby that does not happen.

If she had had her termination when she had asked for it, the question of developing sepsis and so on would not have arisen, we would never have heard of her and she would be alive today.

Regarding the socioeconomic risk, we take everything into account. However, it is not taken into account in current Irish legislation, under which we can only take into account risk of death or risk to physical or mental health, which should be considered together.

Senator Lynn Ruane

Deputy Clare Daly

I apologise in advance for not being here to hear the responses to my questions but I am due in the Dáil. I will read the transcript of the proceedings after the meeting. I found the presentations very helpful. Dr. Boylan said in his presentation that the eighth amendment has caused grave harm to women, including death. I welcome Professor Arulkumaran's clarification for Senator Ruane of the Savita Halappanavar investigation team. My understanding of what he said was that the legislative position did have a serious impact on the clinical professional judgment. In that context, and in regard to Professor Arulkumaran's statement, does this arise because of the artificial divide between health and life? It is a fine line that can change in that often one is waiting for a situation to become life threatening. Would the removal of that distinction tidy up that matter?

We hear a lot that Ireland is a safe place to give birth. Is it not the case that many of the countries that are better than us have quite a liberal abortion regime and it is not, therefore, an argument that because we do not have abortion in Ireland we have safe maternity care? The countries rated higher than Ireland have a liberal abortion regime. Perhaps the delegates would elaborate on how that is linked to our ability to access abortion services in Britain.

I would like to discuss the abortion pill, which ties into the area of resources. Last week, the head of obstetrics and gynaecology in the UK said that in her opinion the legislation in the UK needs to be changed to allow nurses and midwives to make the abortion pill available. They currently make this medication available in cases of missed miscarriages and they carry out vacuum aspiration. Is this not a way in which to deal with a resources issue? As this is an approved medical pill that is certified in Ireland, why cannot it be administered in a GP's office by a nurse? Given the number of people who access it in the first trimester there is no real resources required. Perhaps this could be teased out further.

On consent, is it not the case that whereas normally the patient dictates his or her treatment, the woman's ability to consent, because of the eighth amendment, is diminished? I am thinking particularly in cases of people who are happy to parent but were brought to court because they did not want a caesarean section, it was deemed that the life of the unborn was threatened by their decision and, therefore, an action was taken to cut across their opinion.

I apologise for throwing these issues in together, but will the delegates address the points made?

Professor Sabaratnam Arulkumaran

I will start with Savita's case which was very clear. There are certain conditions in which a disease can escalate steeply and there is no time. By the time the condition is recognised one has missed the boat. For example, the maternal mortality rate in cases of severe sepsis is between 20% and 40%. If the mother develops septic shock, the figure rises to 60%. For every hour treatment is delayed, the chances of maternal mortality occurring rise by 6%. There is no time to waste and a clinician must recognise that the mother is going into septic shock, has a fever and a high pulse rate. However, because there is a heartbeat the clinician starts to dilly-dally. There is no question that the medical practitioner should be given the opportunity to act.

The second question was about the dispensing of tablets by nurses, pharmacists and so on. The crucial issue in liberalising termination is that it must come under regulation. As Dr. Boylan mentioned, it must come within the remit of a medical council, or a nursing council if nurses are to be allowed to dispense. The most important point is that the patient be registered with some clinical medical professional, whether it be a nurse, a midwife or a doctor, who could say the patient was at such a gestation period and that such a medication had been given. This person should give a telephone number to the patient in order that she could call if she was to experience fever, have a high pulse rate or bleeding in order that she could make immediate contact. There is no medical procedure without risk. The moment the patient feels something is wrong, she should be able to ring and gain access to health services in order that it can be managed. There are a number of countries which allow nursing and midwifery professionals to prescribe and administer the drug, but they always have communication and a centre which can deal with complications should they arise.

Deputy Clare Daly

An ordinary GP would be such an avenue.

Professor Sabaratnam Arulkumaran

A GP would be fine.

Dr. Peter Boylan

The removal of the distinction between health and the risk of death would certainly be very helpful in assisting women and their doctors to reach a decision. Ireland is a very safe place in which to give birth, but it is not the safest in the world. The margins are quite small, but it is a very safe place in which to give birth. However, if we did not have access to the United Kingdom, our maternal mortality rate would shoot up because women would access unsafe illegal back-street abortion services. That is undeniable. The best example is Romania when Ceauescu came to power, on which I have provided information in my position paper.

There is a nurse practitioner programme which allows nurses and midwives to gain prescribing skills. That happens in maternity units nowadays. As Professor Arulkumaran said, it is important that they have backup and a telephone number and so on.

On the issue of consent, the Deputy mentioned forced caesarean sections because of a concern about the condition of the baby. That is very rare. It does happen, but it is extremely rare and I am not really sure what the eight amendment has to do with that issue. It is more about a clinician's concern about a woman's capacity to make the decision to continue a pregnancy. These are pregnancies which are well into term - 38, 39, 42, 43 and 44 weeks - and which involve significant foetal concerns which are not related to termination of pregnancy.

Dr. Meabh Ní Bhuinneáin

I concur with Dr. Boylan on the consent issue. On the measure of safety, I urge the committee to widen its deliberations to consider serious morbidity which may include psychological and social morbidity. I believe we are measuring the wrong outcome if we look purely at mortality figures. The delegates at last week's meeting alluded to the fact that one could not see the national and sub-national data in mortality rates. One has to look for more qualitative data.

Finally, something was said earlier about babies being left to die and that phrase has been used here before. References were also made to injections into the heart and so forth. Could Professor Arulkumaran clarify that he was referring to parents who are experiencing fatal foetal abnormality or some other situation where the prognosis is that life is not possible?

Professor Sabaratnam Arulkumaran

Yes, in the UK practice I mentioned earlier, if there is a fatal foetal malformation, it is very distressing for the parents to look at the baby gasping a few times and dying. We have counselling, repeated counselling and discuss it with them. If it is anencephaly, for example and there is no brain, just a little bit of tissue there or a major spinal defect where most of the organ systems will be paralysed and so forth, then we would offer that. If the mother says "No", that she does not want to have foeticide done and will take the consequences, then we say "Okay". We terminate the pregnancy and sometimes the baby might be alive. We just leave them there to really grieve with the baby and then we take it on. Many of the mothers, as Dr. Boylan mentioned earlier, want to do a registration, they want to have a funeral, to have a footprint of the baby taken and they like to remember that baby. Mother to mother, though, it varies quite a lot. There are some mothers who do not want to even look at the baby because they are worried that it might affect them and come back to them like a dream later on. We offer but if they do not want it, we do not force them.

Deputy Ruth Coppinger

The phrase "babies left to die" would be quite offensive and insulting in those circumstances.

Professor Sabaratnam Arulkumaran

If it has a guaranteed, no-survival chance because of malformation then we leave it but if it is a normal baby, as Dr. Boylan said, at 23 weeks we make every effort to give all of the support needed.

Chairman

Thank you. Deputy O'Connell is next and she has six minutes.

Deputy Kate O'Connell

We are deep in this process now. In terms of Professor Arulkmaran's opening statement, it really depends on whatever question one asks. What I am asking here is what we are trying to achieve. If we are trying to achieve something that is politically palatable or palatable to the wider public who, for some reason, people within these Houses seem to think are not engaged in this process, then we are going down the right road in this committee. We are trying to deal with the issue of the almost 5,000 women travelling to the UK. I was on a flight home from the UK last week and as I walked up the aisle, I wondered who on the plane was travelling back.

What we should be trying to achieve at this committee is the provision of appropriate maternity care for the women of this country without fear of political consequences for our own careers. We should be doing our job as legislators and we need to be brave here.

We have listened to many experts in the past few weeks, including the witnesses before us today but we keep talking about women as if women are some sort of abstract concept. I am one of those women. When I present myself in the Coombe Hospital to have a baby, I have a reasonable expectation that I will come out the other side alive and that my children will not be left without me. Professor Boylan said that the maternity strategy does not have women at its centre. If women are not at the centre of the maternity strategy, as we discussed at the Committee on Health, then where are we going in this country? There is this idea that we cannot trust women in this country with their own medical decisions. I totally agree with the Professor that risk depends on where one is in one's life. If I am told at 42 - in a few years time - that I have a high-risk pregnancy, I am not going to risk not coming out the other side but if I was 42 and having my first child, that would be a completely different decision. As one of the witnesses said, the individual nuances of cases present grey areas. I think it was Professor Boylan who said that but I might be attributing it to the wrong person. This has been made clear to the committee and those who are ignoring it are just putting their heads in the sand. We cannot allow for every permutation of every gestational development, every kidney function, every liver function or heart function of every individual and come up with some sort of formula whereby we, in here, allow women to do X, Y or Z with their lives.

I thank the Deputy for raising everything that she raised and I completely agree with her, 100%. I would recommend that legislation should, instead of saying this, that or the other, refer to it being discussed with the woman and, based on the women's request, a termination is offered if she wants it. That is based on 60 years experience in the UK and that is a perfect example of what is happening. It is not uncontrolled but is registered and these things are discussed. Otherwise, we are just, as the Deputy said, pussyfooting around, trying to invent reasons to do it.

That will not be the main objective. If the committee wants to bring in legislation, I would recommend looking at the UK and following that. If the committee does not want to look at the UK it can look at the others, but the legislation there is quite liberal.

Dr. Peter Boylan

We should repeal the eighth amendment and replace it with legislation along the lines recommended by the Citizens' Assembly which gave it very deep consideration.

Dr. Meabh Ní Bhuinneáin

The result of the Citizens' Assembly is an example of deliberative democracy. We need to ensure the Irish electorate have an opportunity to show their opinion.

Deputy Jan O'Sullivan

It is very hard to follow Deputy O'Connell, who is certainly worth listening to. I thank the witnesses. I have read the presentation Professor Arulkumaran made to the Citizens' Assembly. Clearly women can go to Britain. We have abortion, but it happens to be in Britain. The professor presented figures from South Africa showing a 91% decrease in deaths from unsafe abortions when it was legalised. Yesterday I attended the launch of the UN report on the Sustainable Development Goals. The reality of women who die on the African Continent because they do not have access to a place like Britain is very stark.

Professor Arulkumaran presented graphs showing the reduction in abortions after legalisation in France, Italy and Turkey. I ask him to outline the reduction in abortion following legalisation so that we can be clear that we are talking about either unsafe abortions or legal abortions.

Several people have referred to the anniversary of the death of Savita Halappanavar and the sensitivity and difficulty for her family. Senator Mullen - I am sorry he is not here - referred to another woman who died. The witness did not have time to respond to the question because he had gone over his time. Is that the same woman referred to last week by the master of the Rotunda Hospital? If it was, it was a very different interpretation of why that woman died. I will give the witness more time to respond to that issue raised by Senator Mullen. His statement as to the reason that woman died does not seem to be true.

My final question is to Dr. Ní Bhuinneáin and perhaps to Dr. Boylan. Deputy Naughton asked about training and systems, and people having conscientious objections. When representatives of the Irish College of General Practitioners appeared before the committee, they made it clear that somebody with a conscientious objection has an obligation to refer the case to somebody who does not who will deal with the issue. Is that the same for obstetrics and gynaecology? If so what would be the practice whereby somebody in a hospital in the west of Ireland or the mid-west in my case can be certain that they will have access to the care they require irrespective of the geography?

Dr. Peter Boylan

I am not familiar with the details of the woman who died in London that Professor Malone mentioned. I cannot illuminate on that.

Training is a function of the institute. The skill sets are there already. Early terminations with tablets can be done through GPs surgeries and clinics, and by nurses who are certified to prescribe.

A person with a conscientious objection has an obligation to refer the woman on to somebody else who will have a different view. That is what they must do.

Dr. Meabh Ní Bhuinneáin

I concur on conscientious objectors. Not all termination services will occur in the hospital sector. In time if abortion is liberalised in Ireland, early first trimester termination with medical management will occur in the community. Therefore the access to practitioners is possibly more streamlined in many areas around the country. If there are clusters of conscientious objectors that limit the geographical access for women and girls to services, the Medical Council is very clear at the moment - it will revise again in response to legislation - that the duty of care continues. Trying to arrange a transfer and access is part of that duty of care. A conscientious objector must have a very sincere belief in the ethical dilemma and be conflicted with it. It is not just a convenient opt-out by the professional. The testing of conscientious objection may become part of the assessment of competence and become a training issue.

The Deputy said that we have abortion; it is in the UK. It is not the perception of all women. Some women may get a late diagnosis of foetal anomaly at 22 or 23 weeks. The timeline to make a decision to seek support, to mobilise resources and to self-refer to the UK does not allow them to complete that in two or three weeks. We are familiar with women who have continued pregnancy even though that was not their desired option. We need to be careful that we do not allow that to become a commonly used phrase. Referring to my previous comment, we cannot underestimate the morbidity that we are not measuring at the moment.

Professor Sabaratnam Arulkumaran

I agree that if the legislation had been different, Savita's case would not have happened.

Deputy Bernard J. Durkan

I thank the witnesses for giving their time and for the evidence they have presented today. I have a question on the chilling factor.

On the issue of women or girls who may have accessed abortion pills through the Internet, I understand that there have been situations in Northern Ireland where prosecutions have taken place. Is there evidence that such prosecutions have happened here?

One of our Northern members alluded to a case but it was not in his jurisdiction and it did not inform today's position.

Chairman

We will try to seek that information.

Deputy Peter Fitzpatrick

I welcome the witnesses here today. The committee has been talking a lot about the safety of abortion for women. I would like to hear from Dr. Boylan about how safe abortion is for the baby in the womb. It seems to me that we must be prepared to say, here and now, that abortion is never safe for the baby. With abortion, the baby's life always ends. How does Dr. Boylan feel about introducing a procedure that would ask doctors to do the opposite of what they have always been asked to do? We have always trained doctors to save human lives. Abortion would expect doctors to end human lives.

Dr. Peter Boylan

From a mother's point of view, we have heard evidence that it is much safer than pregnancy. The mortality rate of mothers from abortion is in the order of one in a million. It is much higher, obviously, in pregnancies that continue on. We need to talk about the belief systems that people have. Many people hold the very firm and sincerely held belief that it is morally wrong in all circumstances to perform an abortion. They firmly believe that it is morally wrong to end a foetal life. That is absolutely true, those views have to be respected and they are quite widely held.

Deputy Mattie McGrath

I thank the witnesses for staying with us.

During the last hearings on this issue held by the Oireachtas in 2013, the former Senator, John Crown, asked obstetricians, including the masters of the Rotunda and National Maternity Hospital, if they knew of any instance where doctors were prevented from intervening to save a woman's life because of Ireland's legal ban on abortion, namely, the eighth amendment. All the doctors said they did not know of any instance. Does Dr. Boylan agree with their evidence?

Dr. Peter Boylan

The most egregious example is Savita Halappanavar. She died as a consequence of the eighth amendment.

Deputy Mattie McGrath

Deputy Mattie McGrath

Deputy Jonathan O'Brien

This is really a straightforward "Yes" or "No" question. During the debate on the Protection of Life During Pregnancy Bill, the legislation was described at the time as being necessary to provide certainty to the legal profession as to when terminations could be carried out. In my opinion, we, as legislators, failed to do that with that legislation. Not only did we fail the medical profession, we failed women in general. Do all three witnesses agree that we can ill afford to do that again? Do they agree that a decision by this committee to repeal the eighth amendment would send a clear and positive message to the medical community?

Dr. Peter Boylan

Yes.

Deputy Jonathan O'Brien

I wish to discuss issue of risk. I note that Dr. Boylan mentioned earlier how different people will assess risk, especially woman. Dr. Boylan gave the example of someone who was trying in vitro fertilisation for years. She may assess risk differently from someone who may be in her 40s with a family. Therefore, the views of the woman need to be incorporated into the decision. Does Dr. Boylan agree that it would be practically impossible for us to legislate for the risk in primary legislation, given those scenarios? Does he agree that the issue of risk would be best looked at in guidelines or regulation?

Dr. Peter Boylan

Yes, I think it would be impossible to legislate for every individual circumstance. Life is untidy and so I do not believe we can legislate for every particular circumstance in human life – that is simply not possible. I think it should be a decision between the mother – the woman herself – and her care-giver, whether a doctor, nurse, midwife or whoever. That is the right environment to make that decision because of the inherent variation from one individual's circumstances to another. I do not think we can legislate for it.

Deputy O'Brien asked about guidelines. The more we can direct guidelines to the decision being a case of one between the patient and the doctor, the better. I also think that we should absolutely repeal the eighth, but not put anything else in the Constitution. Legislation is the place to deal with this.

Deputy Jonathan O'Brien

Is the Professor of the same opinion?

Professor Sabaratnam Arulkumaran

Yes.

Chairman

It is just as well. Professor, you have a flight at 7 p.m. so I think we need to get you into a taxi.

Deputy Jonathan O'Brien

I have one final question. I was reading through the appendix that the Professor provided. The issue of counselling came up. I know that this is an issue some people who are opposed to terminations have raised. This is the issue of a reflection period or a cooling-off period when a woman decides that she wishes to have a termination. I note that we have also heard evidence that any delay in providing a termination can also increase risk. Is it the Professor's opinion that we should never have a situation where there is mandatory cooling-off or reflection period, as some people have called for?

Professor Sabaratnam Arulkumaran

I agree with what Deputy O’Brien is saying. We have to give counselling about the advantages of continuing with the pregnancy and the risk of termination etc. If she makes the decision and she still wants to proceed with the termination of pregnancy, then that should be final. There should not be a mandatory two week period of thinking that she might change her mind. If she says on her own that she needs some time to think about it, that is not mandatory, but that is a different question altogether. Increasing the gestation causes more complications in terms of terminations.

She has to wait in personal agony for two weeks. By and large, we do not recommend that so-called mandatory waiting period.

Dr. Peter Boylan

That is a relevant point for women who have to travel to the United Kingdom because by the time they have made the decision, gathered the money, made arrangements for children at home and travelled over to, say, Liverpool, to stay in a hotel on their own, they have spent all of their money, perhaps having borrowed from a bank or a credit union, and it would be very hard for them to change their mind at that stage. They are committed, whereas if they were in this country, they would have more time to consider their options and there would not be the panic and the emotional pressure to get on with it and make a decision they might regret when, if they had had more time here, they might have made a different decision.

Dr. Meabh Ní Bhuinneáin

It is international practice not to introduce measures that introduce delays. However, we are moving from one extremely restrictive practice to debating what is best for society in Ireland. Ultimately the electorate will decide how liberal the result will be.

Chairman

I thank our three guests for attending. We very much appreciate the fact that Professor Arulkumaran travelled to be here because he is under time pressure. I also thank Dr. Boylan and Dr. Ní Bhuinneáin for their attendance. We really appreciate their thorough answering of the questions posed by members.

Sitting suspended at 5.15 p.m. and resumed at 6 p.m.

Joint Committee on the Eighth Amendment of the Constitution díospóireacht - Wednesday, 18 Oct 2017

Risks to Health, Including Physical Health, of Pregnant Women: Professor Sabaratnam Arulkumaran, Dr. Peter Boylan and Dr. Meabh Ní Bhuinneáin

Professor Sabaratnam Arulkumaran

Dr. Peter Boylan

Dr. Meabh Ní Bhuinneáin

Professor Sabaratnam Arulkumaran

Professor Sabaratnam Arulkumaran

Professor Sabaratnam Arulkumaran

Dr. Peter Boylan

Dr. Meabh Ní Bhuinneáin

Dr. Peter Boylan

Dr. Meabh Ní Bhuinneáin

Dr. Peter Boylan

Dr. Meabh Ní Bhuinneáin

Professor Sabaratnam Arulkumaran

Dr. Peter Boylan

Dr. Meabh Ní Bhuinneáin

Dr. Peter Boylan

Professor Sabaratnam Arulkumaran

Professor Sabaratnam Arulkumaran

Professor Sabaratnam Arulkumaran

Dr. Peter Boylan

Dr. Peter Boylan

Dr. Peter Boylan

Dr. Peter Boylan

Dr. Peter Boylan

Dr. Peter Boylan

Dr. Peter Boylan

Dr. Peter Boylan

Dr. Peter Boylan

Professor Sabaratnam Arulkumaran

Professor Sabaratnam Arulkumaran

Professor Sabaratnam Arulkumaran

Professor Sabaratnam Arulkumaran

Professor Sabaratnam Arulkumaran

Professor Sabaratnam Arulkumaran

Dr. Peter Boylan

Dr. Peter Boylan

Dr. Peter Boylan

Dr. Peter Boylan

Dr. Peter Boylan

Dr. Peter Boylan

Dr. Meabh Ní Bhuinneáin

Dr. Meabh Ní Bhuinneáin

Dr. Meabh Ní Bhuinneáin

Dr. Meabh Ní Bhuinneáin

Dr. Meabh Ní Bhuinneáin

Dr. Meabh Ní Bhuinneáin

Dr. Peter Boylan

Dr. Peter Boylan

Professor Sabaratnam Arulkumaran

Dr. Meabh Ní Bhuinneáin

Dr. Peter Boylan

Professor Sabaratnam Arulkumaran

Dr. Meabh Ní Bhuinneáin

Dr. Peter Boylan

Dr. Peter Boylan

Dr. Peter Boylan

Professor Sabaratnam Arulkumaran

Dr. Meabh Ní Bhuinneáin

Dr. Meabh Ní Bhuinneáin

Professor Sabaratnam Arulkumaran

Dr. Peter Boylan

Dr. Peter Boylan

Dr. Peter Boylan

Professor Sabaratnam Arulkumaran

Joint Committee on the Eighth Amendment of the Constitution díospóireacht -
Wednesday, 18 Oct 2017