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

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.

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.

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

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.

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

I can substitute for Senator Gavan if that is agreed.

That is fine. I call 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.

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?

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

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

Professor Sabaratnam Arulkumaran

I can answer the first question about risk and whether we can categorise it as low risk, medium risk and high risk. There are problems in trying to categorise because risk is a continuous process. What can start as a little bit of risk can be a medium risk or a high risk within minutes to hours.

Therefore, it is sometimes dangerous in acute conditions to classify risk. A typical example is Savita Halappanavar. In her case, sepsis became severe sepsis and then septic shock within hours, so it is difficult. To take other conditions, for example, if the mother has renal disease or cardiac disease, that again can change very rapidly. What we might think of as a minor risk or mild risk in a renal condition, if she gets superimposed preeclampsia or hypertensive disease, it can suddenly become moderate to severe. The risk is something we can sometimes predict but we cannot judge, especially in pregnancy, because of rapidly changing sequences. Unlike a non-pregnant patient, pregnancy is quite dangerous both in the antenatal and intrapartum period.

Professor Arulkumaran used the terms low, medium and high risk, whereas the terms the citizens used are grave risk and serious risk. Those are not medical terms and are more legal terms.

Professor Sabaratnam Arulkumaran

They are medical terms, but what the medical people should understand or will understand is that what appears to be low risk can become high risk within minutes or hours in the antenatal, intrapartum or postnatal period. For example, we can say she is at low risk of thromboembolism but she can suddenly become medium or high risk. When it comes to termination, it has to be judged based on what is perceived by the clinician at that time. If it is a question of low risk and no termination, by the time one waits for it, it can become medium or high risk very suddenly.

Would Dr Boylan like to come in on the question of risk?

Dr. Peter Boylan

There is a great personal interpretation of risk so what some person may feel is a low risk, another person may feel is a high risk. In the context of pregnancy, which is a very dynamic process where risk can change and the disease process can deteriorate very rapidly, women will approach risk in a different way. I think it is important to take women's viewpoints into consideration when we are dealing with them in the management of pregnancy - it is their lives that are at risk. Some women will risk anything to have a baby. For other women, for example, a woman who is 40 years of age and has four young children at home, who has diabetes which is deteriorating, and who finds herself pregnant and knows that if she continues with the pregnancy, her diabetes will get worse, her eyesight might be affected and her kidneys might deteriorate and so on, for her, that is not an acceptable risk. For a woman in her first pregnancy after, say, years of IVF, she may well be willing to accept that risk. So, while we can describe risk as low, middle and high, it is the woman's interpretation of what the risk is to her personally that is critically important in how we deal with women who are pregnant, and that side of it really has to be taken into account.

Does Dr. Ní Bhuinneáin wish to come in on this?

Dr. Meabh Ní Bhuinneáin

In some situations it is possible to provide some likelihood. When it comes to some categorical variables, one can talk about probability and the likelihood of something happening. In general terms, however, it is not possible to define in a clinical situation and it is an arbitrary decision. Even categorising somebody as having high blood pressure is just based on where we drew a line in the population. In terms of helping the members to deliberate, the language in the Citizens' Assembly in trying to differentiate between serious risk when it comes to health as opposed to life is not going to be supported, by definition.

If the decision is taken to repeal the eighth amendment and allow for terminations in limited circumstances, is it the position of the witnesses that we need to address the issue of criminalisation regardless of the circumstances that may or may not be decided by this committee? Would the three witnesses be in agreement that the issue of criminalisation has to be addressed and that criminalisation obviously needs to be removed?

Dr. Peter Boylan

Yes.

Dr. Meabh Ní Bhuinneáin

Absolutely.

That is a short answer.

Dr. Peter Boylan

The Deputy asked about training, resources, personnel and so on. With regard to training, that is the function of the institute. The skill levels required in termination of pregnancy, every trained obstetrician possesses, so we are more into resources and so on. It is well known that the Irish maternity services are under-resourced - that is no secret. The maternity strategy is supposed to be addressing that issue and we look forward to increased and more appropriate investment in the health services in the future. In a broad sense, yes, we would require more investment, more personnel and so on. The training issue is something that can be quite easily addressed because the skill sets are there.

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.

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?

Does the Senator have further questions?

I will take them one by one.

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.

I believe that every person's viewpoint has to be respected. If termination is introduced into Ireland and legalised, there will be facilities for people who are uncomfortable with whatever the circumstances of the termination of pregnancy are. For example, there will be some physicians who are comfortable with termination for pregnancies where the baby has little or no hope of survival and there will be others who are uncomfortable with that. Other clinicians will be comfortable with termination of pregnancy for whatever reason; there will be others who would resist that. The full range of ethical positions and personal opinions is out there but the most important person in all of this, of course, is the woman who is pregnant. It is her concerns we must address.

Would Senator Mullen like to ask further questions?

I would like to afford Dr. Ní Bhuinneáin an opportunity.

Dr. Meabh Ní Bhuinneáin

The short answer here today is that it is not about the personal stance on the ethical issue. We in Irish obstetrics are facing a position of uncertainty in knowing where we stand. As most of my 27-year career was spent working in Ireland, with a hiatus in Australia, in recent times I have not had to make that personal decision. I would individualise it, however, for the care of the individual mother. As in Dr. Boylan's statement, the mother may determine before she has a test that she is not going to have a termination under any circumstance but might change her mind. I believe that clinicians, as we evolve and if we were working in a different legal environment, might start in a position where we would not engage in termination of pregnancy under any circumstances short of the protection of life in pregnancy. Over time, however, I suspect that the individual nuance of the cases will provide many grey areas for us to have to use ethical decision making to face the moral distress that is involved.

Dr. Boylan has been involved in supporting and drafting Labour Party legislation. He attended the launch that would bring in abortion. He also said that he has been involved in London and the United States. Has he ever been involved in the carrying out of an abortion outside of what one would call medical interventions? Up to what stage of pregnancy would it have taken place?

Dr. Peter Boylan

I think that is an inappropriate question to ask me and I am not going to answer it.

I beg to differ on the appropriateness of the question. People will draw their own conclusions about Dr. Boylan's answer.

Professor Arulkumaran has written several scholarly articles on the injection of potassium chloride into the heart of an unborn at around 21 or 22 weeks as the most desirable method of terminating a pregnancy. Regardless of what method is used at that stage, does the professor agree that in that moment, a child is being killed?

Professor Sabaratnam Arulkumaran

As I said earlier, in medicine there are always two options. If there is a little malformation for which we are carrying out a termination of pregnancy at 21 weeks, if we do not do the foeticide and if the baby comes out alive then it becomes a dilemma for the mother and the caregivers. This is taken into careful consideration and the issues are discussed with the parents about whether they would like to see the baby coming and having a few gasps and dying, when even if one supports the baby it will die. The option can be to do that or to have the foeticide and do the termination. Globally this is a well-established process and it is not something new to me or my practice. It is an established process globally.

In page 5 of his presentation Professor Arulkumaran says that abortion is not associated with physical or mental health hazards but he only quotes the Royal College of Obstetricians and Gynaecologists. Is the professor aware of distinguished research by Fergusson and others that says abortion is associated with adverse mental health sequelae, particularly in women who are young and vulnerable or where there is a history of mental illness?

Professor Sabaratnam Arulkumaran

I have read the literature as much as I can, and even the recent literature, but I have taken the college opinion. There are individual papers that have opposing views.

Is the professor familiar with Fergusson's literature?

Professor Sabaratnam Arulkumaran

No.

Dr. Boylan claims that the evidence suggests those countries that do not provide abortion tend to have falling or lower rates. The fact is, according to the best available-----

Dr. Peter Boylan

I did not say that.

I am sorry, I will go back to the document. Did I misquote the doctor?

Dr. Peter Boylan

I believe the Senator said they tend to have falling or lower rates if they do not have abortion.

Yes, where abortion is legalised, in liberal regimes for want of a better word. Does Dr. Boylan not accept that Ireland, with one in 19 pregnancies ending in abortion, has just a fraction of the rate of abortions that have taken place in Britain where nearly 200,000 abortions take place each year? In some cases these are late-term abortions because there is no time limit for even relatively minor disabilities such as cleft palate. Does he not accept that this indicates the protective effect of the Irish law?

Dr. Peter Boylan

All of the international evidence is that in countries where there is a liberal law or where they change from a restrictive law to a more liberal law, the rate of termination falls. It must be tied in, however, with health education, contraceptive education, sexual health education and so on. It cannot really be looked at in isolation.

Does Dr. Boylan accept that the accessing of abortion pills is irrelevant in the sense that it is as much of an issue and a problem in abortion jurisdictions as it would be in Ireland?

Dr. Peter Boylan

No. It is categorically not an issue wherever abortion is legalised and the abortion pill is freely available through clinics, hospitals and doctors' surgeries and so on. As it is illegal here, any woman who imports pills into this country faces a criminal prosecution and 14 years in prison. That is an unacceptable position for women to find themselves in.

Does Dr. Boylan acknowledge a difference of opinion between him and Dr. Abigail Aiken, who he quoted last week and who seems to be at pains to stress the safety of abortion pills? Dr. Boylan has spoken about the relative danger of importing or using abortion pills.

Dr. Peter Boylan

As the Senator will probably appreciate, I was referring to when a person imports pills from an undocumented source - especially into this country - and we are not sure where the pills come from. It is well known that some medications that are supplied over the Internet are not what they purport to be. There is another issue of concern, which is that women will be taking these pills without medical supervision and that has its own inherent dangers. There is also the psychological impact on women. One can picture a young woman in an apartment who has managed to get the pills. She is terrified that she will be found out for having taken the pills - as has happened in Northern Ireland - and that she could end up being prosecuted. That has a huge further psychological impact to her, on top of the distress of having a termination of pregnancy. No woman goes out in the morning or wakes up and says "Ah sure I will have a termination today". It is a very stressful process and women remember these things for the rest of their lives.

Further to the question I asked earlier, if abortion was legal in Ireland would Dr. Boylan be willing to carry out abortions in the way they are carried out in Britain and at the various terms they are allowed there?

Dr. Peter Boylan

I would wait to see the legislation in Ireland. I believe that the recommendations of the Citizens' Assembly are interesting. When one takes a group of 100 people, puts them together and educates them about the realities of abortion from all sides of the coin, the group comes up with the recommendations such as the Citizens' Assembly came up with. I would wait to see-----

Senator Catherine Noone resumed the Chair.

Senator Mullen's time is up.

Dr. Peter Boylan

I would wait to see the legislation in Ireland and what it proposes before I could answer the Senator's question.

Very briefly, I will ask Dr. Boylan the same question that I asked of Professor Arulkumaran. Is he aware of the Fergusson research around the mental health sequelae of abortion?

Dr. Peter Boylan

As the Royal College of Obstetricians and Gynaecologists' guidelines and position papers take into account the entire world literature, the Senator can take it that the Fergusson paper was referred to and analysed.

Is Dr. Boylan across its detail?

Dr. Peter Boylan

No, but I take the word of the Royal College of Obstetricians and Gynaecologists in London, which has all of the international-----

I have a final question for Professor Arulkumaran. The professor evokes a situation where Ireland is dangerous, despite the fact that we have not had any criminal prosecution of doctors and despite the fact that we do not have a history of mothers losing their lives because of the lack of abortion in Ireland. The professor's own report into the Savita Halappanavar affair did not claim that. The doctors involved in that case did not claim that it was down to the law in Ireland but that it was down to mismanagement of a situation. Has Professor Arulkumaran ever referred to or commented on - by contrast - findings made by the Care Quality Commission in England? For example, in its spot checks on the Marie Stopes clinics, which is an abortion provider in the UK, the commission found as recently as five months ago that some 400 botched abortions had been done in a two-month period. Has the professor ever commented on the problems with the provision of abortion in England and the adverse health effects for women, leaving aside the fatal effects for the unborn?

This will be the final comment from the witness.

Professor Sabaratnam Arulkumaran

As a reference, I have given the health statistics that are published for 2016. The detailed report can be found from that.

Has the professor commented on the problems?

Professor Sabaratnam Arulkumaran

All the details on complications are given in that report. What does the Senator mean by the term "botched abortions"? Can he explain that to me? No he cannot.

A botched abortion is a situation where a mother suffers adverse health, for example, in the case of an Irish woman who died in a taxi coming from a Marie Stopes clinic, or a situation where a baby is alive after the procedure and is left to die.

Allow the witness to respond, and this is the end of this questioner's time.

Professor Sabaratnam Arulkumaran

That would not happen if Ireland would allow the abortion here. The mistake is not of the Marie Stopes clinic. The mistake is of Ireland for not providing abortion services.

(Interruptions).

I could not hear Professor Arulkumaran. Could he repeat what he said?

Excuse me. I was out of the Chamber because a vote was called in the Seanad, which does not happen in other committees, but that is a matter for another day's work. Would Professor Arulkumaran reiterate what he said, and then I will move on to the next speaker?

Professor Sabaratnam Arulkumaran

The question was why a woman who went to England and had an abortion in a Marie Stopes clinic died in a taxi on her way from it. We need to analyse the root cause of that. The root cause is that Ireland is not providing abortion services here. If that woman had had access to abortion services here and if she had had a complication, she would have gone to a hospital here. There are many cases of Irish women, 70% to 80% of Irish women, who have surgical terminations of pregnancy in England because they go and come back on the same day, whereas 60% to 70% of women in England have medical abortions.

Professor Arulkumaran accepts that women have died as a result of-----

Professor Sabaratnam Arulkumaran

No. Only two deaths were reported in five years, in 290,000-----

That is what has happened-----

Excuse me-----

Professor Sabaratnam Arulkumaran

That is two in a million.

I have to move on to the next questioner.

I accept that, but can I make one final point?

I have already-----

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

(Interruptions).

Is this a point of order?

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.

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.

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

It depends on the complexity of the problem. For example, some congenital heart anomalies are not detectable until around 18 to 20 weeks when a detailed ultrasound scan is done. It is worth noting that only about 50% of all congenital abnormalities of the heart are diagnosed antenatally. That is a universal figure, no matter how good the scanning is, so there are problems in that respect.

We can diagnose conditions such as anencephaly very early on in pregnancy, but sometimes more complex problems are not apparent. However, certainly by 20 weeks, we should have been able to diagnose the most obvious or the severe ones. It is not always possible though and there is often a bit of uncertainty about the outlook in a condition, and women are followed throughout the pregnancy when there is an abnormality and they are continuing on with the pregnancy.

In general, we would have to legislate for at least 20 weeks to give very accurate diagnostic assessments-----

Dr. Peter Boylan

Yes.

-----for most foetal abnormalities, as opposed to fatal foetal abnormalities.

Dr. Peter Boylan

Yes.

In terms of risk, and this is a question for the three witnesses, currently we are very restrictive in Ireland. It has to be when there is a real and substantial risk to the life of the mother. Dr. Boylan said, and I assume this is corroborated by the other witnesses, that the woman does not have any discussion in this. The medical professionals make that assessment and the only opinion the woman can offer is to refuse a termination. Is that correct?

Dr. Peter Boylan

Yes.

If we were to liberalise and change, surely the woman's view in terms of risk should be taken into account, not only in the context of the risk to her life but other issues well.

Dr. Peter Boylan

Yes.

Is that the normal procedure in other-----

Dr. Peter Boylan

It is, and particularly in obstetrics it is very much a partnership between the midwives and doctors and the woman going through the pregnancy. We would discuss with women, for example, indications for induction of labour for a caesarean section, for how often she should attend, whether she wants an epidural in labour and so on. Women are involved in these discussions the whole way through, but the problem with the current legislation is that it is up to the doctors to make a decision and then to advise the woman that her life is at risk and she needs a termination of pregnancy to minimise that risk or remove the risk. However, it is a fine line. The only way one can find out whether one has made the right decision is not to do a termination and, if the woman dies, one has made the wrong decision. That is the only way a doctor will know for definite that he or she has made the wrong decision. It is an unacceptable environment in which to practise medicine in 2017. Also, the lack of involvement of the woman in making the decision is not acceptable.

Dr. Meabh Ní Bhuinneáin

If I may comment on that, I would have a slightly differing opinion, with respect. The medical ethics used at the clinical coalface include the autonomy of the woman at all times and her supporting partner and family. The provision of her involvement in the discussion is not purely just to receive advice and information but it is an informed consent process over time, if the time allows. In general, if the woman is aware that time is not allowing, she makes her decision quite quickly, but in some situations informed consent is a process and it is revisited over hours and days, if time allows. Women may choose to opt out of life-saving procedures when their life is at serious risk if they have the capacity to do so. Our duty as clinician providers is to assess their well-being and ability to have capacity, and capacity may be an issue in distressing circumstances with psychoses, drug use or intellectual disability. We would involve other professions in helping us reach that decision if there is any concern over it, where time allows.

The reality is that the woman can only opt out. She cannot opt in.

Dr. Meabh Ní Bhuinneáin

Actually, no. Informed consent in modern obstetric practice means the partnership is not just equal, the woman is the centre. Her autonomy is respected. There is much implied consent used in work on a day-to-day basis in the sense that checking of the receipt of information, the tell-back of the information and if this what the woman agrees with is taken in many forms of communication, including verbal and non-verbal, written and non-written.

Is Dr. Ní Bhuinneáin talking about Ireland or outside it?

Dr. Meabh Ní Bhuinneáin

I am talking about Ireland.

Dr. Ní Bhuinneáin is saying, as it stands, that women are consulted in the context of a life-saving termination taking place.

Dr. Meabh Ní Bhuinneáin

Yes, and over a period----

In the sense that they could request. Is Dr. Ní Bhuinneáin saying that is possible?

Dr. Meabh Ní Bhuinneáin

Yes. In my experience, outside a tertiary institution, the commonest reason in our current practice for invoking the protection of life in pregnancy is with ruptured membranes before viability. That is where the waters have gone around the baby and the mother is at risk of the subsequent impact of infection. That process of information, education and communication with the woman starts from the time we are giving the diagnosis. It is a process over time. It is not a single act. While the witnesses have advised that there may be uncertainty, the timeline to advancing to more serious signs of infection, what we call sepsis, and then to times where the mortality rate significantly goes up, what we call septic shock, are very variable among women. We are always conscious of that because, as I mentioned, we are measured in retrospect if there is an adverse outcome, but we do not have that ability to see ahead at the time. Communication, information and consent are changing and evolving over time. The paternalistic approach to consent in Irish medicine across many domains is evolving over time as medical ethics develop over time.

There are obviously diverging views here on this fundamental issue of whether the woman has a say in requesting a termination to save her life. Dr. Ní Bhuinneáin is saying that a woman has a say and can discuss this with her clinician and they could ultimately come to a decision, but realistically it is only the clinician who can decide at the end of the day. Am I right or am I wrong on that?

Dr. Meabh Ní Bhuinneáin

The current legislation allows us to document and then get a second opinion, if time allows, on the reasons we consider that in these circumstances the woman's life is at risk. Medical emergencies do not necessarily happen in an hour or in three hours. This might go on through the night and into the early morning. There is still time, which is the fourth dimension, in this decision making process.

Dr. Peter Boylan

We certainly discuss everything with the woman, as the condition evolves. Absolutely, that is the way it happens. The decision as to whether a woman's life is in danger is the doctor's decision and not the mother's decision.

How much time have I got?

The Deputy has one and a half minutes.

I want to ask about the procurement and use of abortion pills. Do the witnesses believe that because they were involved in an illegal act and committed an offence under the Protection of Life During Pregnancy Act, for which they can be prosecuted, that the effect on young vulnerable girls in a crisis pregnancy is so chilling that they are discouraged from accessing medical care if the termination goes wrong?

Dr. Peter Boylan

The two complications are haemorrhage bleeding and infection. It will certainly have an effect on a young vulnerable girl, who takes the pills and then has more bleeding than she would anticipate and must go into hospital and her fear is being asked what happened. If she has an infection, it may become a little bit more obvious what she has been trying to do. She does not know whether while in the hospital a doctor, midwife, secretary may report her case to the police. That will have a chilling effect on her and adds to her distress.

I thank the Deputy and appreciate that he remained within the time limit. Senator Buttimer has ten minutes altogether.

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.

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

The experience in France, Italy and Turkey is that once termination of pregnancy is legalised, the abortion rate comes down. The only reason for that, is that it is combined, as Dr. Boylan mentioned, with good post abortion contraception. It is a very clear distinction that it comes down without any difficulty. Second, because medical termination of pregnancy is available, things are getting safer and safer. The World Health Organisation document shows that the chance of the mother dying during a termination in the first trimester is 0.1 per 100,0000, which is minimal. As the gestation period increases, so do the complications and so on go up and illegal abortion comes to the fore when she is in the later period of gestation and runs into difficulties. The answer is that legalisation of abortion brings the termination rates down. That is the experience not just in one but a number of countries, including South Africa.

Dr. Meabh Ní Bhuinneáin

The other reason is that liberal practice evolves over time and that is the difficulty with definitions. Already it has been raised here as to how to define a serious risk to mental health as was the case in the UK, in which a member of the institute has commented on. The law will be tested when it is in use. In spite of the best efforts to legislate in appropriate language, allowing some freedom in regulation would be advisable.

Dr. Peter Boylan

I agree with Professor Arulkumaran that all the evidence is that the rate of termination comes down once more liberalised legislation is introduced for all of the obvious reasons.

Senator Buttimer referred to the floodgates opening. There was a great deal of concern expressed by some people about the inclusion of suicide as a risk to the life of the mother in the Protection of Life in Pregnancy Act, and that women would abuse this provision. That has not happened. I do not think women will abuse any legislation.

Termination is a very distressing thing to have to go through. I should also say that women who have terminations for babies with serious abnormalities grieve for those babies. They name them, they really feel deeply about it and they are very angry at having to travel abroad. I do not think members should underestimate that anger. It is out there, justifiably.

I thank the witnesses. Dr. Boylan came before the committee that I chaired and he is one of the most refreshing witnessed I have met.

If we as a committee recommend no change, or if the Irish people recommend no change, what advice would the witnesses give to members who must compile a report, given their medical and professional backgrounds?

Dr. Peter Boylan

Groundhog day. We will be back. The committee has to do something now.

If the witnesses were to speak directly to the people today, what would they say to them?

Dr. Peter Boylan

They have got to do something now. The eighth amendment is no longer fit for purpose. It has caused enormous problems and huge distress to women. It needs to be repealed and the legislators need to legislate. I hope that when members come to introduce legislation they will be guided by what we said here today and by the findings of the Citizens' Assembly.

Professor Sabaratnam Arulkumaran

The questions asked were whether we would do terminations for this that and the other reason. The question raised in my statement is whether they would send a woman to prison for doing this, that and the other. The answer is going to be totally different.

That is true whether it is the legislator or the people who are concerned. In my view, the questioning has to be done the other way around. Is it possible to imagine putting 4,800 women behind bars in Ireland every year? I can produce the list if the committee likes.

Go raibh maith agat.

Dr. Meabh Ní Bhuinneáin

The approach I hope to see going forward is that of deliberative democracy. The principle has been recorded in the Citizens' Assembly. If it could be replicated in the more open debate of deliberative democracy then perhaps some voices that have been silent before will participate at this time.

I will now move on to all other questioners. The first person to have indicated was Deputy O'Reilly, who has six minutes.

I spoke already.

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

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.

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.

Would Dr. Boylan like to add anything?

Dr. Peter Boylan

I have nothing else to add.

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.

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.

Senator Ruane has six minutes.

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.

Would using social status as an indicator be possible if we moved towards risk to health in general?

Dr. Peter Boylan

"Social status" in its broadest term,-----

Dr. Peter Boylan

-----including what Professor Sabaratnam Arulkumaran mentioned about abuse, drug use and other complicated social issues that people are unfortunate enough to experience.

Dr. Meabh Ní Bhuinneáin

Regarding the Senator's second question on social indicators, we use those on a daily basis in providing services. We check understanding if the woman does not have the first language of the country or the health providers. We use gender inequality and check for domestic and gender-based violence. We use immigrant status. We use ethnicity. If we are not the major ethnicity of the country in which we are receiving reproductive health services, we tend to do worse than those who are of the major ethnicity. It is more difficult in deliberation over life. Where we are not familiar with the different ethnic groups, there may not be the same responsiveness to their needs. We also use social indicators in health assessment and risk assessment in part of our education communication strand of care.

In terms of the committee's deliberations, social indicators probably best fit when it comes to determining where services are provided. If they are not integrated fully in the public health system, those who are most socially disadvantaged through urban or rural poverty will still not be able to succeed in gaining equitable access to care.

I thank Dr. Ní Bhuinneáin.

Deputy Naughton is the next questioner. She has six minutes.

I thank the witnesses for appearing before us. Dr. Boylan stated that doctors were currently in a position of having to interpret the Constitution. From his experience, even if it is just anecdotally if he does not have figures, does that happen on a weekly or monthly basis?

I take it that the best outcome for clinicians is that abortion be allowed purely on medical grounds between a doctor and a patient. Is that correct? Perhaps the other witnesses might wish to address that point. Is that the best outcome from a clinical point of view?

Dr. Boylan stated that he could not imagine any doctor in Ireland contemplating performing an abortion after 23 weeks. Will he expand on that? It is an important point for this committee.

Dr. Ní Bhuinneáin works in a level 3 hospital. In the event that abortion becomes available in Ireland, would it require centres of excellence? Would regional hospitals be equipped to perform these procedures? How would she envisage conscientious objection working in a smaller hospital as opposed to an acute one?

Perhaps Dr. Ní Bhuinneáin will answer the last question first.

Dr. Meabh Ní Bhuinneáin

Regarding the use of language in terms of termination for "medical reasons", there is not enough clarity in "medical reasons". We are discussing health and risk to health, but "health" is broader than "medical reasons". As to the use of the word "doctor", there may in time be task shifting to other cadres of specialist staff who come from a nursing or midwifery background. "Clinician-woman relationship" is the broader interpretation of the Deputy's question.

It is not possible to be proscriptive on every indication as to why a woman or girl may request a termination. The commonest reasons where there are liberal laws are that the pregnancy is not affordable for her at this time or her other responsibilities would be compromised at this time, for example, the impact on other people for whom she is responsible. If we become restrictive as regards purely clinical indications of physical and mental health, which is what the Citizens' Assembly has recommended, we will miss the other social determinants of health and well-being that influence women's decisions to seek termination of pregnancy and we may not legislate for those women who are currently self-terminating for what we may not consider to be socioeconomic or medical reasons.

Regarding the Deputy's question on model 3 hospitals, a safe termination of pregnancy is part of what is considered basic emergency obstetric care. Centres of excellence have an important role in termination care where the woman has complex medical disorders or the foetal complexity may prove difficult to manage in a rural hospital setting that is in a model 3 unit. There is still one unit in a model 2 hospital. Occasionally, there will be reasons to attend a tertiary unit where there is a maternal foetal medicine specialist practising with a full multidisciplinary team. In general, termination of pregnancy would be considered within the core competencies of general obstetricians and gynaecologists and general practitioners, GPs.

Dr. Peter Boylan

As to interpreting the Constitution, the most egregious example of that was the Miss P case. Everyone present is aware of it and the appalling vista that it presented. The doctors were unable to make a decision as to whether they could turn off her life support because of the presence of a foetal heartbeat. That is the best example. In terms of day-to-day practice, the issue would not arise on a daily basis. In a busy unit like a tertiary referral centre, however, it would be an issue and people would wonder whether it was legal to provide a termination in a particular case.

Another problem is that cases going to the European Court of Human Rights makes the eighth amendment difficult on the ground for practising staff.

The best outcome is the interaction between the patient and the health care professional. There is no question about that. No two situations are identical and many nuances are involved in all scenarios. Some people have different attitudes towards risk, for example. All of these factors need to be taken into consideration. The best person to make those considerations is the patient with her health care professional.

Twenty-three weeks and on is where foetal viability is now regarded as a practical proposition. Many of those survivors at 23 weeks will have significant disabilities, for example, cerebral palsy and blindness, and be completely dependent for the rest of their lives. It is not that everything is fine at 23 weeks - it is not like that at all - but if a baby is born at 23 weeks, physicians in Ireland will do everything to care for that baby. For example, if we have a woman with a severe condition who is at 23 and a half weeks with twins and we tell her that she is really sick and we need to deliver her, and if she asks us to do everything to save the babies, we will perform a caesarean section and intervene in the best interests of those babies. That is theoretically a termination of pregnancy, but we will in fact do everything to look after those babies when they are born. It is not a simple situation and viability changes. When I was in training, a baby born at 28 weeks had little chance of survival. The situation is improving all of the time with intensive neonatal care, advances, research and so on. Is that a satisfactory answer?

It answered my question. I asked another question on whether Dr. Boylan had much experience dealing with women who had taken an abortion pill without medical assistance. Could he comment?

A brief response, please.

Dr. Peter Boylan

Very little experience. If a woman presents to a hospital bleeding and in the course of having a miscarriage, we do not know whether she has tried to use abortion pills. We take at face value whatever she says. Obviously, we look after her regardless and do not make any judgment call whatsoever. If she wants to tell us, that is fine, but I have little experience of that. That is probably because most of them are successfully completed at home and they do not need to attend hospital. They would be in the minority.

I thank the witnesses for being here today. My first question is to Professor Arulkumaran. In regard to the British health system, all health care systems are dependent on their being able to recruit and retain medical staff, which has become a huge issue recently. We heard last week that Liverpool Women's Hospital has had to delay admissions of Irish women with a fatal foetal abnormality. In the context of Brexit, there seems to be a large immigrant cohort in the UK health service. In that regard, is it correct to say that we cannot depend on the British health care system being capable of delivering for people outside of the British jurisdiction?

Professor Sabaratnam Arulkumaran

I thank the Deputy for her question, which would probably be more appropriately answered by the Minister for Health. It is true that there is a shortage of doctors, nurses and ancillary staff in the health services and that the level at which these services can be provided might be questioned. I will try to explain how the system is organised in regard to, for example, terms of termination of pregnancy. I work in St. George's Hospital, which provides this service for all of south-west London, despite that there are seven different hospitals in the area. The vast majority - 60% to 70% - of terminations are carried out by prescription. Every week, there are two clinics and two operating lists for suction termination. We manage all the referrals for south-west London. I do not know the population of Ireland versus south-west London. One clinic offering suction termination in each of the big cities in Ireland would be sufficient. Whatever the outcome of Brexit there will be no need for concern if legislation providing for liberal abortion is enacted.

Dr. Boylan referred to legislators having to grasp the nettle in terms of legislating for reproductive health. In regard to the 99% versus the 1% in terms of Ireland and Malta, is there a model of best practice within the European Union that he believes Ireland should emulate?

Dr. Peter Boylan

There are a number of them. Ireland always seems to look to the UK for examples of how things should be done in this country, particularly in the medical sphere. The UK legislation dates back to the 1960s, such that it has been in operation for more than 50 years now. We do not have to adopt it. This is not reinventing the wheel. There are many countries within Europe from which we can pick and choose legislation. There are very good analyses of the different types of legislation throughout Europe but the common theme of all of them is that 99% of women in the EU have access to safe termination in the first ten weeks-first trimester of pregnancy. That might well be a starting point.

Which one would Dr. Boylan choose?

Dr. Peter Boylan

I cannot point to any particular one because they all have their own little peculiarities. If one gets a good analysis of them, then one can pick and choose.

Assuming there is a referendum passed, it is hoped in favour of a straightforward repeal, legislation would then be required. Is Dr. Boylan saying there is also a need for regulation, and following on from that medical ethics guidelines and so on, which would be the function of the various representative organisations? Regulation would be done by the Department of Health, I presume.

Dr. Peter Boylan

Yes.

At what point is medical ethics addressed? Does it follow on from the making of the regulations or is it done in tandem?

Dr. Peter Boylan

If the eighth amendment is repealed, the Protection of Life During Pregnancy Act 2013 still stands. Under that Act, the only indication for termination of pregnancy in this country is a risk to the life of the mother. That would stand. There would be no change in that respect. We would still have the most restrictive legislation in Europe. In regard to regulation and so on, as the Deputy correctly mentioned, regulation is the function of the Department of Health. It would regulate where the procedure could be done and so on. The Medical Council interprets medical ethics and provides guidelines for practising obstetricians. If we step outside those guidelines, we are subject to sanction by the Medical Council, which can, although rarely, result in the withdrawal of a right to practise in the country. That is how the system would work. Education and training would be the function of the Institute of Obstetricians and Gynaecologists.

In regard to conscientious objection, are there hospitals here that have a governance arrangement that is determined by religious ethics such that they could not be able to operate within-----

Dr. Peter Boylan

Any hospital that is owned by the Catholic church would be forbidden by its rules from facilitating any terminations of pregnancy, as well as contraception, sterilisation and all other issues integral to women's health. There are some maternity units and gynaecological services in hospitals around the country that are owned by religious and do not carry out sterilisations or Mirena coil insertions owing to heavy periods as opposed to for contraceptive purposes. There is a bit of hypocrisy going on.

What proportion of hospitals is involved?

Dr. Peter Boylan

The number is relatively small.

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.

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.

I thank the delegates for their presentations. I will begin with Professor Arulkumaran. Unfortunately, we are coming up to the fifth anniversary of Savita's death. There are still people who claim that her death had nothing to do with the law but rather with mismanagement in the particular hospital. I want to nail that one right now. In the recommendations made in Professor Arulkumaran's report he said: "We also believe that legislative factors affected medical considerations in this case and that this resulted in a failure to offer all management options to the patient". Is that correct?

Professor Sabaratnam Arulkumaran

Absolutely.

At the time Professor Arulkumaran recommended that the Oireachtas consider the law, including any necessary constitutional change. That was one of his recommendations.

Professor Sabaratnam Arulkumaran

That is correct.

Is he very disappointed or surprised that it has taken five years since the death of Savita for the Oireachtas to act?

Professor Sabaratnam Arulkumaran

I am disappointed because at the time of the inquiry I made some effort to contact the Institute of Obstetricians and Gynaecologists. We had discussions with the institute which stated nobody else would do anything and that the medical community had a responsibility to recommend some changes, but that did not happen. I hope it will happen under Dr. Peter Boylan.

Is Professor Arulkumaran surprised that it has taken five years for the Oireachtas to even discuss the issue?

Professor Sabaratnam Arulkumaran

I am surprised because we carried out that inquiry and made that specific recommendation, yet nobody really took note of it or took charge of progressing it.

Professor Arulkumaran states in his presentation that we could formulate a list of conditions, but that it would never be able to cover all health conditions which may arise. Is that correct?

Professor Sabaratnam Arulkumaran

That is correct. As an example, if a woman has an underlying renal disorder which was not picked up before the pregnancy started and develops a condition - during pregnancy conditions such as pre-eclampsia, diabetes and hypertension can develop - her condition will deteriorate rapidly. If we had proceeded according to stratification, we would have missed that lady. That is why it is sometimes not that easy. Even if we had a list, it could not cover the entire spectrum.

Professor Arulkumaran is probably aware that the Citizens' Assembly insisted on risk rather than substantial risk being considered. It was the citizens participating in the assembly who did not want the words "substantial" or "real" being included. Does he think that would be wise and that risk alone should be the basis of any health-based ground for abortion?

Professor Sabaratnam Arulkumaran

My personal view is that a spectrum should be considered, rather than focusing on health issues alone. Health issues are limiting. We must also think about women's rights and the other sociodemographic issues we are discussing. My advice is that only focusing on death and health and such things would restrict and might not give the greatest advantage. If the legislation is to be changed, the best approach is to take all facts into consideration to see what is best for the women of Ireland.

By "the women of Ireland" Professor Arulkumaran means the 4,800 women whom he says are leaving the country and the further 20% whom he says are taking medical abortion pills which they source online. We heard evidence on this matter last week which included a study which had been carried out. What is his opinion on legislation which does not cater for those women whose health is not at risk but who are going to access abortion services?

Professor Sabaratnam Arulkumaran

I would proceed according to the woman's wishes. If those 4,800 women could access the same care which they can receive in England and be assessed by a doctor who could offer an abortion legally, that would be the best outcome for the women of Ireland.

I would also like to ask Dr. Boylan a few questions. He has spoken about the genie being out of the bottle because pregnant women can access abortion pills on the Internet and also find out quite a lot about them. It is not like 1983. What percentage of abortions would be covered by the 12-week period recommended by the Citizens' Assembly?

Dr. Peter Boylan

It would probably be more than 90%.

In Dr. Boylan's view, would that be the best way? He mentioned legislation that he has looked at, without citing any particular country, where it is at a woman's request in the first trimester. Would that be the best basis for abortion legislation?

Dr. Peter Boylan

I think it probably would be the most honest way of dealing with it.

Why does Dr. Boylan say honest?

Dr. Peter Boylan

I mean instead of shrouding it, as it is in the UK, where effectively it is on request. Two doctors have to sign a document but effectively it is on the request of the woman, for whatever reason - risk to health, socioeconomic reasons and so forth.

Has Dr. Boylan any experience of women who are denied an abortion deciding not to have one? In other words, is this going to continue, whether legal or illegal? Would that be his view?

Dr. Peter Boylan

I think it is going to continue anyway, legal or illegal. My experience would be very limited. I returned to Ireland in 1988 from the United States and I have been working here ever since, so my experience would be quite limited.

My last question is on late-term abortions which have come up a lot at this committee. Indeed, they have come up a lot in Ireland generally, with images being used by anti-abortion groups. How frequent are these post-23 week abortions? What percentage of the overall abortion rate do they represent and for what reasons would they be carried out at that very late stage?

Dr. Peter Boylan

Probably under 1%. Yes, they would be under 1% and would be carried out for fatal anomalies that become apparent later in pregnancy.

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.

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.

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

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 am getting frustrated at this stage. We spoke about floodgates opening and I always find this humorous-----

Does the Deputy have a question for the witnesses?

It is as if there are gates and behind them are lots of pregnant women trying to get through but if we open them, they are just going to run wild. Pregnancy is something that progresses. If a woman is not going to get sorted in her GP's surgery, she is going to go onto aerlingus.com or ryanair.com or wherever. I hate being racist against Irish people but we are trying to get an Irish solution to an Irish problem here. I cannot understand why we are - to use Dr. Boylan's word - "shrouding" the decision in terms of trying to keep this person or that person happy. I think it is right to say that we are all abortionists in this room. It is just that some of us are willing to face up to the realities while some are willing to shove it onto someone else's plate.

The Deputy has gone over four minutes now; perhaps she would like to ask a couple of questions.

Dr. Boylan touched on the anger women feel when they have a diagnosis in pregnancy. There is no greater pain than such a diagnosis, as he knows. These are babies who are wanted. At 22 weeks into a pregnancy, to be told that is just heartbreaking and for us to sit here and judge those women for what they choose to do with their bodies and their lives is appalling. We were asked to "get real" here by Professor Binchy a few weeks ago. I think we need to get real on this committee. The witnesses before us need to spell it out, in black and white, to us today that there is no way that we can legislate for everything we can think of here because in five years time, something might happen. Something might be developed that will enable children to survive at 22 weeks and that will be great and we will use it but we cannot-----

Would the Deputy like to give the witnesses an opportunity to respond?

I think they need to spell it out here and not be afraid today to do so. They need to say that this is where we are and any sort of pussyfooting about is going to lead to uncertainty and women's lives are going to be at risk. Spell it out to us; I think we need it in black and white today.

We will have to have brief responses because the Deputy has used up her time.

Professor Sabaratnam Arulkumaran

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.

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.

In the UK we have a few conscientious objectors. The General Medical Council regulation in the UK is that if any doctor - GP, physician or obstetrician - does not want to do something, it is their responsibility to refer the case to somebody in time and in the right place so that procedure can be carried out. I am sure the Medical Council here will also have the same regulations to prevent women being bypassed or delayed because of conscientious objection.

Do I have more time?

The Deputy may seek a point of clarification, but her time is up.

Obviously the referral time is critical. Does the HSE have an obligation to ensure that there are appropriate numbers of personnel in particular areas?

Dr. Meabh Ní Bhuinneáin

Part of the organisational development at national level is to initiate the national women and infants programme office. We now have an accountability structure for all services nationally as opposed to allowing services to develop ad hoc in maternity units according to who was serving in those areas. The responsibility for providing care, if it becomes legal in Ireland, will fall under the programme in the HSE in co-operation with the primary care elements.

I presume Professor Arulkumaran can confirm the statistics for France, Italy and Turkey.

Professor Sabaratnam Arulkumaran

That is true. The WHO has reported that the introduction or liberalising of abortion in France, Italy and Turkey has reduced the number of terminations mainly because of post-abortion contraception. Many women will accept a long-acting reversible contraceptive such as an IUD or implant. Therefore they do not get pregnant or run to the same cycle. I am sure the same process will happen if it is legalised and takes place in Ireland. When these women go to Britain they do not have the opportunity to have that particular counselling and have contraception there. Here they are not going to come and say, "I had an abortion. I want contraception", unless they go and say they want contraception. As Dr. Boylan mentioned earlier, if termination is liberalised, it needs to be linked to contraception services.

That is an important point.

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?

In the Citizens' Assembly, of the citizens in that group who voted for termination without restriction, 92% voted to limit gestation to 12 weeks, which is intervention at not later than 12 weeks. Does this meet the witnesses' requirements? I am mindful of the fact that we have discussed tragically unfortunate cases, and one case in particular that has been most under discussion. There are pre-exisiting conditions that have the propensity to accelerate dramatically if they are in combination with other conditions. At this stage, in relation to that case and to others, and in the event of there being evidence to that effect, will each of the witnesses say that they would now be prompted to intervene more quickly? During my time in the House I have dealt with a number of cases in this area where tragic consequences took place. That is the basis for my question.

Professor Sabaratnam Arulkumaran

On the first question of whether there has been any prosecution in the Republic of Ireland similar to in the North, I would not know. I have not heard about any.

The Deputy's second question was about the limits of gestation for terminations, based on the outcome from the Citizens' Assembly. The records in the UK say that nearly 90% of terminations are done under 12 weeks. That would cover a vast number of them.

With regard to the third question posed, there are special circumstances where the mother may have an illness and if it were to escalate there could be organ damage. There might be some special provision given and taken. The Citizens' Assembly vote, in terms of percentages, reflects those dilemmas in some way. We must take everything into consideration. If it is just on request or for social reasons or otherwise, then it might be 12 weeks and that would cover 90%. There must, however, be a provision to have a later termination for those who have illnesses or conditions that can escalate.

Dr. Peter Boylan

I am not aware of any prosecutions in the Republic of Ireland for the use of the pills. The Citizens' Assembly 92% were in agreement with terminations up to 12 weeks. The Deputy asked about pre-existing conditions and if we would intervene quicker now. Does he mean in relation to the Protection of Life During Pregnancy Act?

With or without that, or irrespective. Would that apply anyway? In the event of a change in the legislation, how do the witnesses see themselves reacting in that situation?

Dr. Peter Boylan

As I have said, if the eighth amendment is repealed, the Protection of Life During Pregnancy Act 2013 still stands. The only reason one could perform a termination in Ireland would be if the mother's life was at risk. That would absolutely stand and it would be up to the Members to introduce legislation for all the other reasons that the Citizens' Assembly proposed.

Let us assume that the legislation has been passed and there is a new regime. Does that in any way alter the degree to which, in an advanced stage of the pregnancy, it might be decided to intervene with a view to termination at an earlier stage than currently proposed?

Dr. Peter Boylan

I am not absolutely sure that I understand the question.

In the event of a repeal of the eighth amendment and the legislation being changed, does that alter the manner in which the practitioners might deal with a case where the circumstances I have outlined might prevail. In other words, does it show that there is a difference now as opposed to what prevailed previously?

Dr. Peter Boylan

Undoubtedly yes.

Dr. Meabh Ní Bhuinneáin

I am not aware of the chill effect and legal precedence. In terms of delaying access for post-abortal care, the fears among vulnerable groups are not always about criminalisation. The fear is of social rejection, disclosure to family and friends and the consequences in their immediate community. The Deputy framed his question around whether the legislation would meet our requirements. With regard to the women and girls we serve, having no reason for termination up to 12 weeks will not meet the requirements of all the women and girls who are currently seeking termination of pregnancy. While the diagnosis of pregnancy is made early in most cases, there are still many women who may not reach the self-diagnosis of pregnancy until beyond 12 weeks, although that is becoming less frequent. With education and a comprehensive reproductive care package, in time the earlier diagnosis of pregnancy may occur, especially with younger women but not always with older women.

Is Dr. Ní Bhuinneáin suggesting that better sex education in schools might be of benefit?

Dr. Meabh Ní Bhuinneáin

Absolutely. That is part of the expanded reproductive health care programme. It is an entire education programme in formal and informal education in the youth sector.

Have I another minute?

The Deputy is over his time. Is it a point of clarification?

It is one last question. Evidence has been suggested that where abortion is readily and legally available in a country, the number of abortions decline. What is the basis for that conclusion? Different regimes apply in different countries. Germany has fairly strict regulation of termination of pregnancy. As medical practitioners, are the witnesses aware of the system in Germany as opposed to the UK system?

Dr. Meabh Ní Bhuinneáin

Yes. The restrictive practice in Germany is that the counselling is supposed to be directive counselling as opposed to non-directive. Germany is, however, one of the group of countries, along with the Netherlands, Belgium and Scandinavian countries, where abortion rates have fallen. It is not necessarily clear that abortion rates would fall immediately here because it would depend on the strength of the education programme and access to contraception, including post-abortal care contraception, as the professor has alluded to, and planned contraceptive services in a more informal delivery system than we currently have. In the long-term, if there is liberal termination of pregnancy legislation, we would anticipate a fall in the numbers of women seeking termination. In the short term, unless it is matched by other sex education programmes and other changes in contraception delivery, we might not see that fall immediately.

I wish to have clarification on a point touched on by Deputy Durkan relating to the position in Northern Ireland on abortion pills. Are the witnesses aware of any prosecutions there? This is information the committee will have to obtain and it has been raised already in this committee at other sessions.

Dr. Peter Boylan

Yes, there have been prosecutions there.

That is what we have heard but we would like to know that this is accurate information.

Dr. Meabh Ní Bhuinneáin

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

We will try to seek that information.

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.

On the other hand, there are huge numbers of people who do not share those beliefs. As I alluded to earlier on, there are people happy to perform terminations for all sorts of different reasons and at different gestational ages, depending on their set of beliefs. One has to depend on what a person's belief systems are. Those are influenced by where they grow up, what they are taught in school, their religious background and so on.

How safe is the unborn in the womb? I am asking about the unborn.

Dr. Peter Boylan

One has to come back to belief systems. People who are comfortable in their belief systems that the termination of pregnancy is an acceptable route to go are firmly of the belief that there is not a problem with ending a life in the womb, as the Deputy described it.

Following on from that, does Dr. Boylan believe the baby in the womb should be seen as a doctor's patient with the same rights as everyone else? If he does not, then what rights does he believe the baby should have, given that the baby's heartbeat starts just after three weeks in the womb? When does he think babies should a right to life in law?

Dr. Peter Boylan

One can detect a foetal heartbeat from very early on in a pregnancy. It is important to understand, however, that in the womb one does not have what used to be called a homunculus or fully-formed human from the early stages. There is a huge amount of complex development. When one can see a heartbeat in the womb, what one is looking at is a tube which is pulsating. It is not the heart as we know it. It is important to understand there are complex developments which take place from the beginning of conception right up until us, if one likes. Again, we come back to the belief systems.

Does Dr. Boylan believe he has two patients, the unborn and the mother, or does he believe he has one patient?

Dr. Peter Boylan

When a woman opts to continue with a pregnancy, then we have two patients who we have to take care of during the course of a pregnancy. That is why with ongoing pregnancies, which are the norm, we assess the condition of the foetus and we do ultrasound scans right throughout the whole pregnancy.

Does Dr. Boylan believe the baby has rights?

Dr. Peter Boylan

That is a philosophical question to a certain extent. It is also a question for Legislatures to decide upon.

What makes viability so important? Surely viability is just another stage of pregnancy. The baby is still the same member of the human race before viability as after that point. The only difference is that a baby is a bit bigger and more developed after viability. In countries where abortions are allowed, doctors are expected to ignore the rights of one of the patients, mainly the unborn. This is very different from what happens in Ireland where doctors do their best to save every life. What makes viability so important?

Dr. Peter Boylan

Viability refers to the ability of some babies to survive outside of the womb. The committee heard evidence last week from the masters of the Rotunda and National Maternity Hospital about how we define viability as 24-weeks' gestation. Some babies can survive if they are born at 23 weeks while some babies born at 25, 26 or 27 weeks will not survive because they are not developed enough to survive. Among the survivors, there is a high rate of disability. That is why viability is important. For example, if a mother develops severe high blood pressure at 24 weeks, we will intervene. As the baby is viable, we will make every effort to save the baby. If a woman develops the same degree of hypertension at 20 weeks, there is no point in trying to save the baby because it has zero chance of survival at 20 weeks. That is the difference between pre-viable and viable.

As was stated earlier, this is one of the safest countries in the world for a baby to be born. Dr. Boylan mentioned that this probably is the strictest country in Europe but I believe Poland is a little stricter than are we at present. I want Europe and the world to realise that Ireland is a safe place to have a baby. We have fantastic medical doctors and everything else and look after the child and the mother.

There are two people involved, the unborn and the mother. The point I am trying to make is it is important that the doctor realises he has two patients.

Dr. Peter Boylan

I fully respect the Deputy's viewpoint but the point is that if Ireland did not have access to termination of pregnancy in the UK, as we do, the maternal mortality rate would be very high. The only thing that keeps us having a low mortality rate is ease of access to termination of pregnancy in the UK. That, unfortunately, is a reality.

My problem is that one in every five pregnancies in the UK is aborted and there are 200,000 abortions in the UK each year. The last thing I want to see is Ireland following suit.

We have a fantastic health system in Ireland and it is a safe place to have babies. I want to continue that. I want Ireland to be known as a safe place to have a baby. Perhaps the Government could do more. When a woman presents herself to a doctor and does not know whether she wants an abortion or not, the information she gets from the doctor is important. This is my first time meeting Dr. Boylan and I know he is strong in his beliefs. If someone went to Dr. Boylan with his beliefs or to another doctor with other beliefs, then we have a problem. That is my concern.

I am not criticising Dr. Boylan for his beliefs. In fairness, he has given his honest opinion on every question I have asked. I am giving my honest opinion that if a woman presents herself, whether she is suicidal or raped, she is dependent on that doctor to give her the information. My problem is whether the doctor is pro-life or pro-choice. The woman is vulnerable and we trust the woman but the problem is with the doctor. Dr. Peter Boylan is strong in his views. My problem is if the woman went to him or another doctor.

Dr. Peter Boylan

My views are that the woman's opinion has to be respected once she gets all of the relevant information. Ultimately, she is the person who has to live with the decision. I respect the Deputy's view. I would not be persuading a woman to have a termination of pregnancy and I would not be persuading her not to have a termination of pregnancy. I would give her all of the information. It is up to her to make her decision. That is the role of a doctor as a non-directive counsellor. One has to respect a woman's view. One of the functions of a doctor is not to be an advocate of a particular moral point of view when it comes to termination of pregnancy.

It is also important to respect the doctor's view too.

Dr. Peter Boylan

Yes, but one leaves one's views at the door.

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.

That was a tragic case and there are many differing opinions about it.

(Interruptions).

Deputy Mattie McGrath had the floor and the witness is entitled to answer.

Dr. Peter Boylan

I had the opportunity of reviewing her notes forensically. I may have an unfair advantage in that respect.

Aside from that tragic situation, are there other cases?

Dr. Peter Boylan

Professor Arulkumaran shares my opinion. He also had the opportunity of doing an in-depth investigation, including interviewing all of the relevant people, apart from the one midwife who was on sick leave.

I accept that. However, outside of that tragic case, the Savita case, were there other cases?

Dr. Peter Boylan

Of maternal death?

Dr. Peter Boylan

I cannot think of one off the top of my head.

I also noted that at a previous all-party Oireachtas committee hearing on abortion in 2009, the then chairman of the Institute of Obstetricians and Gynaecologists, Professor John Bonnar, submitted a position paper on abortion only after consulting with all members of the institute. I note Dr. Boylan stated today in his paper that he has also canvassed institute members' opinions. How many did he canvass?

Why did he not undertake a consultation or survey of all the members of the Institute of Obstetricians and Gynaecologists before coming to us today?

Dr. Peter Boylan

I gave every member of the institute an opportunity to contact me with regard to their opinions in respect of the evidence that I would be giving today. I have made it very clear that I am not speaking on behalf of the institute, but I have taken members' views into account in giving my evidence today.

Could Mr. Boylan enlighten us as to what kind of feedback he got, percentage-wise, from members?

Dr. Peter Boylan

Most of the feedback I got in fact was broadly in agreement with the proposals of the Citizens' Assembly.

That was most of it. Did Dr. Boylan get any alternative views?

Dr. Peter Boylan

One or two expressed concerns about the actual implementation of the legislation to be brought forward as the Citizens' Assembly recommended.

But Dr. Boylan did not engage other than giving a view. What way did he advertise or contact them? How were they notified?

Dr. Peter Boylan

They were notified by way of a circular letter from me inviting contributions.

That went to all of Dr. Boylan's colleagues. Is that correct?

Dr. Peter Boylan

Yes, to every member of the institute.

During an abortion procedure, the abortionist often uses ultrasound to help guide the instruments to grasp at its member, the baby. Does Dr. Boylan think that ethically this must be a difficult procedure for an obstetrician to perform? According to statements from the British Department of Health in 2011, the number of doctors unwilling to perform abortions is increasing. Why does Dr. Boylan think that is so? We have evidence of that in other jurisdictions as well.

I am conscious that you are speaking at the moment, Dr. Boylan, but by all means please indicate, Professor or Dr. Ní Bhuinneain, if either of you would like to comment further.

Dr. Peter Boylan

My understanding about the position in the UK – Professor Arulkumaran will probably correct me – is that because most terminations are done outside the NHS, trainees are not gaining the skill-sets. As a result, they are uncomfortable with doing something that they do not have the skill-set to do. I think it might be better if Professor Arulkumaran were to elaborate on that.

Professor Sabaratnam Arulkumaran

Training in termination of pregnancy has not been uniformly given for most trainees. The Royal College of Surgeons of England is trying to reintroduce that. Let us consider the 2016 report. Almost 60% to 70% of the terminations are done medically. Only a small percentage will need surgical termination. I work at St. George's, University of London Hospital. We offer termination by suction termination. Late terminations are very rare. As I mentioned, after 20 weeks a lethal malformation is 1% to 2%. In such cases we do not really have to look at the foetus and dismember, or something like that, because we use medication, like Misoprostol and other drugs, that can procure the termination without difficulty. The past practice of traumatic termination is going away. Mostly, medical terminations are coming into practice.

Surely in the limited cases that it does happen, it is off-putting. Apart from the training issue – I understand that – the evidence is that the numbers of doctors who are unwilling to perform abortions is increasing.

Professor Sabaratnam Arulkumaran

Hospitals really have to specifically take doctors who can perform these cases and train them. In future we will have to revamp. As Dr. Peter Boylan mentioned, there was a stage when the hospitals were giving certain services on contract to private agencies. As a result, most of the cases went to the private agencies and there were hardly any cases to be trained within the hospital, except a few hospitals like St. George's, which I mentioned. We retained the services throughout. That practice will come back again because now those responsible are reviewing the cost. The cost of providing the services in the hospitals will be far cheaper compared to private agencies. It is nothing much to do with doctors' personal wishes; in many cases it is to do with how the services are contracted. I hope it will reverse itself.

Does Professor Arulkumaran think it is all down to cost? Who vets those private agencies?

Professor Sabaratnam Arulkumaran

The hospital trust does it. It gives contracts for cataract, knee replacement, abortion and so many things.

I am aware of that. We are speaking about abortion today. It is all down to cost, so.

There is time for one final point of clarification.

Professor Sabaratnam Arulkumaran

There might be an element of where the doctors do not want to do it. However, we have not done a survey of anything like that to see whether it is because they do not want to do it, because they lack training or because the contract has gone. I will not be able to tease out the reasons or ascertain which is the right reason that fewer people are now keen to offer termination of pregnancy.

Surely we should examine that.

Professor Sabaratnam Arulkumaran

The Royal College put out a statement recently stating it wants to review that and increase the training in this area.

Thank you, Deputy. Deputy O'Brien, you have six minutes altogether.

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.

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.

Is the Professor of the same opinion?

Professor Sabaratnam Arulkumaran

Yes.

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.

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.

In Professor Arulkumaran's opinion, will the rate of abortion for babies with disabilities increase sharply if abortion is legalised in Ireland?

Professor Sabaratnam Arulkumaran

I did not follow the question.

If abortion is legalised in Ireland, will the percentage of abortions increase for children diagnosed with a disability?

Professor Sabaratnam Arulkumaran

It is very unlikely because generally the incidence of lethal malformations is tiny. I do not think the numbers would increase. Those who are diagnosed and cannot have a termination here travel to the United Kingdom to have it done. I do not think the numbers would increase in that particular category.

I thank Professor Arulkumaran. Would anyone else like to answer that question?

Dr. Meabh Ní Bhuinneáin

It is difficult to know, given that currently we do not have systematic screening for a foetal anomaly. There is another issue at play. There is mention in the national maternity strategy of ultrasound, but there has to be a national debate on providing a full prenatal diagnostic service that would include chromosomal testing. The numbers of women in Ireland who have the opportunity to terminate a pregnancy in the case of a disability as opposed to a potentially life-limiting condition are not yet at the level of international norms for those who have that information. We are not yet in a position to anticipate what would happen because we do not yet have organised screening services.

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.