Professor Fionnuala McAuliffe:

The Institute of Obstetricians and Gynaecologists at the Royal College of Physicians of Ireland is the body that officially represents and advises on obstetrical and gynaecological opinion, professional standards, patient care, education and research in Ireland. As such, the IOG has a compelling interest in the contents of the final Bill. We have a responsibility to ensure it will be the best way to protect women's' health and lives, and also allow for the necessary flexibility to cater for future advances in obstetrics.

Maternal health services in Ireland are among the best in the world and pregnant women and their families should be reassured that they are receiving the very best of care during pregnancy. Recent accurate figures have been collected in Ireland in the past three years which show that approximately one woman per 12,000 pregnancies dies in pregnancy. This low rate compares very well with that in the United Kingdom and the rest of Europe. However, we are never complacent and it is our absolute priority to ensure pregnant women receive the very best of care. To maintain these high standards and improve on them, we need to continue to adequately resource maternity services. The situation where termination of pregnancy or delivery of a very premature baby is required in order to avert a substantial threat to the life of the mother is rare, although these situations do occur. The heads of the Bill provide a process that can be accessed to deal with this rare clinical situation when there is a concern about maternal life. This process will require underpinning with robust multidisciplinary guidelines from the Department of Health and the HSE; input will be required from the Royal College of Physicians, the Royal College of Surgeons, the College of Psychiatrists of Ireland, the College of Anaesthetists of Ireland, the Irish College of General Practitioners, An Bord Altranais, the Irish Nurses and Midwives Organisation to mention a few. Robust Medical Council guidelines will also be required.

At all times we remain acutely aware of the potential negative consequences for the unborn when cessation of pregnancy is necessary to protect maternal life. We highlight the fact that enormous additional challenges to clinical management arise when termination is being considered in gestations approaching foetal viability but still extreme prematurity. In current practice, all efforts are exhausted within medical margins of safety to prolong the pregnancy in the foetal interest. Additionally, once the baby reaches a stage when it can survive, it is current practice that every effort is made to support the life of the baby after birth, if medically appropriate. We do not see this Bill in any way providing for late terminations, nor the destruction of the baby and our members would not support this. These are complex difficult cases and a multidisciplinary team approach is required. However, obstetricians are the experienced clinicians in the care of pregnant women and should be central to the assessment of sick pregnant women and any decision-making process when there is a substantial risk to the mother's life.

In this submission we represent the majority view within obstetrics and gynaecology in Ireland following a planned, structured consultative process. In preparation of this opinion on the heads of the Bill we used the content of our positional paper from January 2013, the final text of which had been approved by the institute and circulated to all of our members. Following a request for an opinion on the protection of life during pregnancy Bill, an initial draft was considered and discussed in detail by the executive of the institute and the final text was approved at a meeting on 7 May. The final version has been circulated to all members. In addition, direct contact was made with representatives of all maternity units for comments directly on this document. The response overall was supportive of the institute's written submission.

A number of areas require amendment and the following are the main points. Our full opinion is contained in the written submission. We propose adding a definition of "termination" under head 1. When there is a real and substantive threat to the life of a pregnant woman, the gestation at which the pregnancy is interrupted is the critical factor influencing outcome for the unborn. We suggest restricting the use of the term "termination" to situations where there is no chance of survival after birth such as when a pregnancy is ended before a foetus is viable. The definition of "obstetrician-gynaecologist" for pragmatic reasons will need to be expanded to include those acting in the role of consultant obstetrician-gynaecologist who may be on the general medical register rather than in the specialist division. All Government approved general hospitals, including the 19 maternity hospitals, will need to be regarded as suitable venues to provide these procedures, as necessary. Pregnant women with a severe illness requiring specialised inpatient treatment are often cared for in a general hospital setting with access to coronary care and intensive care units. General hospitals, therefore, must be included. Failure to make these two changes could result in delays in accessing life saving treatment in pregnancy and it is the institute's opinion that they must be made.

Under head 2, in non-emergency situations, whatever the indication, two obstetricians-gynaecologists must be involved in the decision-making process; one obstetrician would be required to examine the patient and sign the documentation and the support of a second obstetrical opinion sought. In addition, where the condition warrants but only then, other consultants on their own specialist register form a team assessment.

With regard to head 3, we accept that, although consultation between two obstetricians-gynaecologists is desirable in the acute emergency case, this may not always be possible and a single opinion would suffice. It is the institute's view that emergency procedures should only be carried out in a hospital setting and I suggest changing the term "health facility" to "hospital setting".

Head 4 concerns the risk of loss of life from self-destruction. The Institute of Obstetricians and Gynaecologists does not differentiate in terms of logistical arrangements between physical or mental reasons for considering a termination. One obstetrician would be required to examine the patient and sign the documentation, and the support of a second obstetrical opinion would have to be sought. We accept there is a need for two psychiatrists, however, as it would be their expertise that the obstetricians would rely upon to determine whether suicidal ideation is true intent and poses a real and substantive risk to the life of the mother.

On heads 6 to 11, inclusive, we support the review process and would like to emphasise the importance of accurate documentation and regular auditing of cases.

Head 12 pertains to conscientious objection. We endorse the current Medical Council Guidelines of 2009, 10.1 to 10.3, inclusive, regarding the options and responsibilities for clinicians with a conscientious objection to participating in certain clinical treatments.

Head 14 concerns regulations. The Institute of Obstetricians and Gynaecologists supports the legislative option of legislation plus regulations, suggested by the expert group on the judgment on A, B and C v. Ireland. We believe this option best addresses the need to protect women as well as health care professionals involved. The regulation aspect of this would allow the necessary flexibility to incorporate future developments in the area of obstetrics.

We ask the Minister to ensure, when developing regulations with the Department of Health, that they are initiated without delay so that robust, safe guidelines of practice can be enacted promptly by the HSE and the Department of Health on this issue. This will necessitate appropriate funding and infrastructural provision. Any changes to regulations, in our view, should be put before the Oireachtas before enactment. Our full opinion on the heads of the Bill is contained in the written submission from the Institute of Obstetricians and Gynaecologists. We would appreciate it if careful attention were paid to it.

The location should include all Government-approved hospitals. The definition of "obstetrician and gynaecologist" should be expanded, and detailed multidisciplinary guidelines should be generated. We are grateful for the opportunity to present to the joint committee the views of the institute. We request that obstetricians have an input into the final Bill as we are the doctors most intimately connected with this issue and who will need to deliver the service.