Dr. Rhona Mahony:

I am very pleased to accept the invitation to attend today. I wish the committee every success in addressing what is a most important and complex issue. I hope I will be of some assistance. We are all present with the primary objective of preserving life. I am the Master of the National Maternity Hospital in Dublin. I am a practising obstetrician and am also a specialist in foetal and maternal medicine. This means I have cared for women whose pregnancies have been complicated either by maternal or foetal disease.

The National Maternity Hospital is one of the busiest hospitals in Europe and delivers over 9,000 babies annually, or one in eight babies born in the State. Our hospital is a tertiary referral centre, which means we look after some of the most complicated pregnancies in Ireland. In addition to looking after our hospital population, we look after women referred to us from other obstetric units around the country. These women require additional expertise in dealing with the variety of complications that may arise either de novo or as a result of pre-existing maternal disease.

The primary reason for my presence today is to help members understand why we, as doctors, need enhanced legal protection in dealing with clinical cases where a pregnant woman may die and where treatment to save her life may include termination of pregnancy.

I wish to make one thing clear today: if there is any chance that a baby will survive at the threshold of viability, every effort will be made to save that baby. That must not be at issue today. We regularly look after babies at the threshold of viability with excellent results by international standards. Our neonatal intensive care facility is a national resource that cares for babies born as early as 23 weeks' gestation and who weigh as little as 500g, or even less in some cases.

At present in Ireland, doctors practice medicine relating to pregnancy with a degree of legal uncertainty. It was as far back as 1861 that the Offences against the Person Act, specifically sections 58 and 59, decreed that abortion was a criminal offence in Ireland, punishable by a life of penal servitude for both the woman and her doctor or anyone who assists her in procuring an abortion. This law remains today. It was to be more than 130 years before the Supreme Court judged that termination of pregnancy was admissible in the very rare circumstance of a real and substantial risk to the life, as opposed to the health, of a mother. As everyone present is aware, the risk to life in this case was the risk of this young girl taking her own life because of her distress at being pregnant. Twenty years later, the anticipated legislation that might have come from this judgment has not been enacted and, therefore, there is a degree of legal uncertainty in how we interpret the Supreme Court judgment and whether the Offences against the Person Act in fact is precedent. It remains law.

In the meantime, it is quite interesting. We have passed a variety of referendums which allow women access to information on termination of pregnancy outside this jurisdiction. We have had a referendum that allowed women to travel to alternative jurisdictions for termination of pregnancy, despite the fact that such a thing remains a criminal offence within this country. We have twice held referendums to remove suicide ideation as an indication for termination of pregnancy but I believe we have not yet managed to address the legal uncertainty surrounding termination of pregnancy in the very narrow, rare confines and context in which we believe there is a genuine risk to the life of a woman - that is, where a woman may die as a complication of her pregnancy but could be saved by termination of the pregnancy. Consequently, in very rare circumstances, doctors are faced with the task of making highly complex clinical decisions based on medical probability but without the luxury of medical certainty. It is imperative that we have the flexibility to make decisions based on medical fact. It is imperative that we have legal protection to do this. The State demands of us that we save life wherever we can and we must do this; it is our job. If a woman is critically ill and it is obvious she is likely to die, that she would be saved by intervening and treating her and that this treatment involves interrupting or terminating the pregnancy, we will not hesitate to do so. Moreover, society and women may be absolutely reassured that we will not hesitate to so do. The difficulty arises when the risk to life is not immediate. For example, a woman who has a serious underlying medical disorder may be sitting in front of one now but the additional burden of the physiology of pregnancy on organs that are already burdened and challenged may pose a highly significant and substantial risk to her life. Doctors must have the flexibility to make appropriate clinical judgment, not based on ideology or philosophy, but based on medical circumstances. This is what the State demands of us.

One must acknowledge that sometimes, tragically, women die during pregnancy. In fact, approximately eight women out of every 100,000 maternities in Ireland die during pregnancy. In some of these cases, they may die either because of direct pregnancy complications or from completely incidental causes such as a road traffic accident. Alternatively, they may die of indirect causes - for example, a woman may have a serious underlying morbidity to which the addition of pregnancy may so challenge her that she may die. This country recently produced a triennial report into maternal deaths in Ireland from 2009 to 2011. If one looks back at maternal deaths, one can see there were six deaths arising directly from pregnancy complications but double that number, 13 deaths, arising in women who had pre-existing medical disease. Five of these women had pre-existing cardiovascular disease, two died by suicide and two of influenza, and there were a variety of other medical causes, including liver disease and lung disease. Interestingly, however, it is my experience that in many cases, women with serious underlying medical disease will choose to continue their pregnancy in the knowledge that they may die. In other words, women will risk their own lives to reproduce. However, some women faced with a significant risk of their own mortality will not wish to continue their pregnancy. This brings one to the highly difficult issue of defining what is a substantial risk to life during pregnancy. Is it a 10%, a 50%, an 80% or a 1% risk of dying? The interpretation of risk is not the same for all people. A woman herself will have a view as to what is an acceptable risk of her dying during pregnancy. Her opinion deserves to be afforded consideration. Clinical flexibility, supported by law, is required. Doctors must be able to make sound common-sense medical decisions based on medical conditions and circumstances and not ever on ideology or philosophy. They must be protected by law in doing this if they are to be able to carry out their jobs to the best of their ability. Members should make no mistake: what doctors wish to do is to preserve life. This is all about preserving life.

In recent months, we have listened to a wide variety of opinion. Some of this opinion has been extreme and absolute, at times unhelpful and, I would argue, at times even misleading. This forum hopefully will provide an opportunity for informed and mature debate. I believe the outcome of the joint committee's important work will underpin society's wish to protect life as far as possible. Perhaps the most controversial issue, which I now raise, is that of death during pregnancy as a result of suicide. Attempts have been made to confuse the risk of death from suicide by quoting figures from the United Kingdom relating to death from all mental disorders and not specifically the tiny number of women, who are under specific discussion here, who present wishing to take their lives during pregnancy. I am not a psychiatrist. I absolutely appreciate that members will be addressed later by specialists in the area of psychiatry and of course I defer to them. However, as a woman, I am offended by some of the pejorative and judgmental views to the effect that women will manipulate doctors to obtain termination of pregnancy on the basis of fabricated ideas of suicide ideation or intent. There also appears to be an assumption that psychiatrists are unable to assess the issue of suicide ideation, which is something they do every day in their clinical practice. I do not believe we have the right to dismiss absolutely the risk of a woman taking her life during pregnancy. It is known that women occasionally, albeit rarely, take their own lives during pregnancy. Women who are so distressed that they will consider taking their own lives must be listened to and believed and need appropriate medical care. That will not necessarily include termination of pregnancy but in a tiny percentage of cases, it just might.

Finally, one should remember the women and children who have brought us here today, and yes, I use the word "children". Let no one in this room forget the circumstances of the X case. This is the story of a 14-year-old child who was raped, who found herself pregnant and who was so distressed by her circumstances that at the age of 14, she wished to take her own life. Let no one forget her because she is real.