Dr. Mary McCaffrey:

I wish to thank the Chairman and other members of the Joint Committee on Health and Children for the invitation to speak here today. I understand that the purpose of the invitation was to gain some insight into how proposed legislation might affect smaller maternity units.

Of the 19 maternity units in Ireland, 12 are manned, or personed, by three consultant obstetrician gynaecologists, supported by junior staff and midwives. There are 12 units of that size in the country and approximately one third of all babies born in Ireland every year are delivered in units of that size.

In putting this presentation together I really am only a conduit for the views of a large number of consultants around the country, as I have consulted with many colleagues in similarly sized units. We have calculated that the people involved in this process have, together, around 280 years of obstetric experience under our belts. We have therefore managed quite a large number of patients, albeit in small units.

It is important for us that the legislation that is finally passed is workable and practical, that it will work equally in all maternity units in the country, that it will work for all medical practitioners, that all medical practitioners who practice in this country as obstetrician gynaecologists will feel well protected under the legislation, and, most importantly, that all patients - regardless of where they deliver their babies or are cared for from a maternity point of view - are treated equally, and that the system will work for them.

I believe it is important for people to understand the day-to-day workings of a three-person maternity unit. On each weekday, there are three consultant obstetrician gynaecologists in the maternity unit. There will be one on-call consultant obstetrician who will look after all emergency procedures, theatre and labour ward. His or her two colleagues will be carrying out theatre lists, operating, doing outpatient procedures or whatever, so they will be within the hospital during normal working days.

Out of hours - say, after 5 o'clock from Monday to Friday - the on-call obstetrician is the only person available on-site at the hospital until 9 o'clock the following morning. At weekends, from 5 o'clock on Friday - in some situations, from 1 o'clock on Friday - until 9 o'clock on Monday morning, that one on-call obstetrician is the only on-call emergency consultant available in that hospital. Obviously, he or she has a team of support staff, but he or she is the only senior obstetrician in the hospital. That is an important point to make in terms of staffing levels. Therefore, there are times when there is no immediate access to a second person on call in a maternity unit. Most people are acutely aware of that. If the on-call obstetrician needs to collaborate with a colleague, he or she endeavours to contact him or her by telephone or whatever.

The other point to make is that when consultants are on annual leave, locum consultants, who are temporary consultants, agency staff or whoever, are brought in to cover, and these are not part of the regular staff in the unit. In general, however, most consultant obstetricians in smaller units endeavour to employ a small core number of persons who are familiar with the unit. In general, we use the same people all the time; they are persons who we consider to be trained to the same level as ourselves. That is how staffing levels work in the smaller maternity units in the country.

We then looked at the decision-making process for the various categories of patient and how we felt they pertained to our practice on a day-to-day basis. I reiterate that I am acting as a conduit for the views of a large number of people and I am trying to put these views together in the most objective fashion for the committee.

We looked, first of all, at women presenting with serious medical conditions, where the pregnancy itself puts the woman's life at risk. The most obvious example is serious heart disease. We felt that, in general, such women would already be under the care of a specialist cardiologist or physician in another hospital or in a tertiary referral centre in Dublin, Cork, Galway or wherever. It was the unanimous view of everybody I spoke to that these patients were best managed in that tertiary referral unit and that we would not be involved as decision-making signatories because we would not have the expertise, as obstetricians in a smaller unit, to decide whether or not a particular woman's pregnancy was compatible with life. Such women will already be travelling to a centre such as the Coombe Women's and Infants' University Hospital. That hospital has a medical clinic with three consultants who specialise. They may be going to Dr. Rhona Mahony's clinic or to Dr. Coulter Smith. However, we felt that in general these were not a group of people with which we would be involved in the smaller hospitals. Even if they presented on our doorstep for whatever reason - for example, in an emergency while on a weekend holiday - it would be inappropriate for any procedure to be performed on them because we would not have the backup of a cardiac anaesthetist or whatever. They would be stabilised and transported back to the place that would best serve their needs.

The second group of women we looked at was the group of women presenting with suicidal ideation or intent. Although we have discussed this among the group, I personally have no knowledge of ever having cared for a woman who wanted to end her life specifically because of a pregnancy, and in my pursuit of information over the past week or so, I have been unable to identify any other consultant who did know of such a woman, which backs up the information we already have - i.e., that this is an extremely rare situation. The consensus among my colleagues was that, as obstetricians in a medium-sized maternity unit, we did not feel we had the expertise to be involved in a diagnosis of suicidal ideation or intent, that we did not have the expertise to decide that a woman's pregnancy should continue, and that such diagnosis should be performed and carried out within the psychiatric services, with signatories from within those services.

We are then down to the issue of whether, if two psychiatrists, or whatever number of signatories are finally decided, say that this woman should have the foetus delivered early in the interest of her health, this should happen in the smaller maternity unit. A number of issues came up in this regard. We felt that if one looked at it in terms of medical services, we had the facilities to do so; however, there were a significant number of reasons people felt it should not happen in a smaller maternity unit. Many members of the committee will be aware, as they represent small rural areas, of how difficult it can be to remain anonymous in such an area. We felt that stigmatisation of women might occur and that anonymity would be extremely difficult to maintain. Some colleagues had issues regarding the skills base, because it was a procedure they had never been involved in and did not wish to be involved in in the future.

Although it is not an issue for this committee today, I must take the opportunity of saying that in the smaller maternity hospitals the gynaecology services and women's health are becoming the Cinderella services of the health services in general. There are a significant number of maternity units in the-----