Dr. Sam Coulter Smith:

This accounts for about 12% of births nationally. We are a tertiary referral centre for both sick mothers and sick babies. We jointly manage maternal morbidity cases with our colleagues from the general hospitals - in our case, mostly the Mater hospital and Beaumont Hospital, but other hospitals as well.

I will provide some figures to put things into context. Of the women we look after, we see about 40 very significantly sick mothers with life-threatening issues annually. As I said, we jointly manage these cases with our colleagues, mostly in the Mater. It is important to recognise that we only have access to intensive care facilities in the Mater Hospital, which is about 400 yards away. That is not appropriate in this day and age. On average, we have approximately five or six cases a year in which interruption of the pregnancy is required to save the mother's life. There are a range of conditions and timescales in this sort of situation. One example is the case of maternal collapse when some sort of immediate intervention is required. Where the mother's life is at risk from something like cancer or significant cardiac abnormalities such as maternal cardiac disease, the risk obviously is not quite so acute but it is definitely there. Then there are situations in which the mother's life is at risk because of complications of pregnancy, such as infection. In that situation, where there is no prospect of the baby's survival, then obviously intervention has to be made.

Dr. Mahony has already alluded to the number of maternal deaths in the country. Most of the big maternity hospitals expect to have somewhere between zero and three maternal deaths a year. That would equate approximately to between nine and 11 cases in 100,000. The causes of death include epilepsy, thromboembolism, breast cancer, uterine rupture, haemorrhage and accidental death.

I would now like to turn my attention, if I may, to the issue of maternal mental health. Nationally we have three specialists who sub-specialise in the area of mental health in pregnancy. All of these specialists are in Dublin. Mental health issues complicate somewhere between 10% and 15% of pregnancies. They are therefore one of the commonest complications of pregnancy, yet they are one of the most under-resourced complications. Life-threatening mental health issues are rare. The incidence of suicide in pregnancy is of the order of one in 500,000. That is based on UK figures. We cannot be sure of the numbers who will feel they are at significant risk of suicide, as many of the patients who currently have suicidal ideation may not interact with our maternity services or our mental health services. They may, in fact, travel to the UK without accessing any of the services in this country. It is important to realise that it is very rare for a woman to claim that she is suicidal in pregnancy and wants a termination of pregnancy.

There are a number of issues that I would like to highlight. The first, on what might seem a small point but is hugely important, is the terminology we use when we talk about this subject. Some people will use the term "abortion", while some will use "termination of pregnancy". It is of enormous psychological importance to a woman who is having her pregnancy interrupted for a life-saving procedure whether we call that an abortion or a termination of pregnancy.

There is the potential for a significant impact on existing services. Our maternity services in this country at the moment are all demand-led and are barely coping with the existing demand on them. We do not know what the demand will be down the line. We do not have the infrastructure, staff or resources - from an obstetric or a mental health point of view - to deal with this new component of service that we may be asked to provide.

The legislation and regulation are important. I welcome the Cabinet's decision on legislation and regulation. The legislation needs to be short and it needs to take into account future developments within medical practice. There needs to be a degree of flexibility within that legislation to deal with the wide variety of clinical scenarios that we face. In terms of regulation, there needs to be a suitable number of qualified doctors involved in a decision to terminate a pregnancy. Those doctors should be on the specialist register. There should be the opinions of at least two senior obstetricians, plus the opinion of whatever specialist is involved. If it is a mental health issue, then obviously a psychiatrist has to be involved. If it is a cardiac issue, then a cardiologist needs to be involved and others as well.

As regards where these procedures should occur, it will depend on the clinical scenario. However, most institutions that provide maternity services should have the ability to provide this service, bearing in mind that some of the smaller hospitals will not have the appropriate mix of specialties to deal with it, and a referral path needs to be made for that situation. There also needs to be an appropriate appeals system with appropriate access to legal opinion and access to the courts where necessary.

Turning briefly to the area of conscientious objection, it is important to realise that we are talking about situations in which a mother's life is at risk. She is at risk of death and in that case, obviously, conscientious objection becomes a lesser issue. I will leave it there but the committee can come back to any of the other issues.