Professor Fionnuala McAuliffe:

As we have heard from Professor Greene, maternal health services in Ireland are among the best in the world. Pregnant women and their families should be reassured that they are receiving the very best of care in pregnancy. One measure of maternal health services is maternal mortality rates, about which we have just heard. Our accurate figures in Ireland show that these rates are approximately one mother dying per 12,000 pregnancies. These low rates compare very well with those in the United Kingdom and the rest of Europe.

Another measure of maternity care is the number of cases of severe maternal illness during pregnancy. This is the number of women who, without timely treatment, risk maternal death. Ireland is one of the leading countries to collect this type of information. The rate of severe maternal illness during pregnancy recorded in Dublin is three per 1,000 pregnancies, which compares very favourably with the Scottish data of four to six per 1,000 pregnancies. However, we are never complacent and it is our absolute priority to ensure pregnant women receive the very best of care. In order to maintain these very high standards and improve on them, we need to continually adequately resource our maternity services.

I will make some general comments on the report of the expert group on the judgment in the A, B and C v. Ireland case. We very much welcome the opportunity to have an input and applaud the expert group report. It is important that obstetricians have legal clarity when making difficult decisions regarding termination of pregnancy or delivery of a very premature baby when treatment is required to ameliorate the threat to a mother's life. The situation where termination of pregnancy or delivery of a very premature baby is required in order to avert a substantial risk to the life of the mother is rare, although it does occur. The majority of cases we see as obstetricians arise in women with prior medical disorders such as severe heart, lung or liver disease, or where a mother develops severe pregnancy-related blood pressure. If the baby is delivered at a stage before it can survive, unfortunately, it will die. However, once the baby reaches a stage where it can survive, it is current practice that every effort be made to support its life. The test to be applied can only be a medical one, to which exact precision and timing cannot be applied. As doctors, we deal with probabilities and cannot precisely predict death or its timing. However, obstetricians are the experts in maternity care and if two senior obstetricians in consultation with the appropriate medical specialties consider there is a substantial risk to the life of the mother which can only be ameliorated by termination of pregnancy or delivery of a very premature baby, we will take this decision. That is our current clinical practice and it is imperative that we be allowed to continue this practice in the interests of pregnant women in Ireland. These are complex and difficult cases and a multidisciplinary team approach is required. However, obstetricians are those clinicians who are experienced in the care of pregnant women and, therefore, should be central in the assessment of sick pregnant women and to any decision-making process when there is a substantial risk to the life of the mother.

I will now make some specific comments on the report of the expert group. Chapter 6 deals with the procedures for determining entitlement and access to termination of pregnancy. On paragraph 6.2 outlining the test to be applied, as stated, it can only be a medical decision with appropriate documentation. On paragraph 6.3 dealing with the qualifications of doctors involved, it is the view of the institute that this should be a consultant obstetrician on the specialist register. On paragraph 6.4 dealing with the number and role of doctors involved, it is the institute's view that it should be two consultant specialist registered obstetricians and gynaecologists, plus, where the condition under review warrants this but only then, other consultants on their own specialist register as a team assessment. On paragraph 6.5 dealing with emergencies, it is the view of the institute that no special provisions are required and that established clinical practice guidelines for emergencies will apply.

In regard to paragraph 6.6 dealing with location, the considerations listed were acknowledged, but it was considered that all licensed general hospitals, not just recognised maternity units, should participate in providing these procedures, as necessary. Mothers with complex medical disorders are often cared for in general hospitals with access to intensive care. Therefore, it is imperative that all recognised licensed hospitals be able to provide these life-saving procedures.

Where neonatal care is not available to care for a very premature baby, and provided the woman's health allows, in uterotransfer pre-delivery to a unit that has appropriate facilities should be considered. This is established current practice in Ireland.

With regard to the formal review process under paragraph 6.7, it is the institute's view that the medical model at the woman's request or by another person acting on her behalf is the preferred option. With regard to the composition of the review panel under paragraph 6.7, it is the institute's view that all specialties are to source and provide from within their appropriately qualified ranks consultants practising in Ireland to form a panel that can be called upon for a second opinion. There should be a minimum of two obstetrician gynaecologists plus other specialties similarly qualified, as appropriate. In obstetrics and gynaecology, the institute would act as a list provider. The panel should be indemnified against possible subsequent legal proceedings and have access to formal legal expertise. With regard to the convenor under paragraph 6.7, it is the institute's view that a nominated person or unit in the Department of Health, whom the woman can access directly, should convene the panel from the list supplied by the professional bodies. With regard to access to courts for appeal and conscientious objection under paragraphs 6.8 and 6.9, these were acknowledged as read and, in the latter case, it was noted that this may extend to other health professionals. With regard to the monitoring system or monitoring review panel under paragraph 6.10, it was the view that these important cases need close monitoring and regular review. With regard to chapter 7, options for implementation, it is the view of the institute that statutory legal protection is required for health care professionals and patients. With regard to alternatives for implementation under paragraph 7.4, it is the view that paragraph 7.4.3, concerning legislation plus regulation, provides the necessary flexibility and protection for health care professionals and their patients.

In conclusion, we are grateful to have the opportunity to participate in the discussion. We respectfully request that the institute have input into the final wording to ensure we are allowed to continue with current practice, which includes the provision of life-saving treatments to pregnant women.