Professor Fionnuala McAuliffe:

Deputy Billy Kelleher asked about after care. We must bear in mind that we are talking about rare clinical cases where a mother's life is in danger or there is a risk of loss of life. It would be a small number of cases and we would offer follow-up in the hospital setting. These are patients with complex medical disorders or perhaps life-threatening obstetrical emergency conditions. As such, they would always be offered after care in the hospital setting. It would be rather unusual for such patients not to inform their GPs of what had transpired, given that, as I said, they are patients with complex medical disorders of which their GPs would usually be aware. They would require long-term follow-up care for that medical disorder, whether it be mental or physical. It would be unusual for the GP not to be aware of the patient's situation. We would always follow up with the patient in the hospital in the first instance.

On the important issue of viability, Article 40.3.3° remains in the Constitution. We are committed to the health and life of mother and baby. It sometimes happens that we have a very sick mother around the time of viability, in which case every effort is made to prolong the pregnancy to allow the baby to get to a stage where there is some chance of survival. If we feel prolonging the pregnancy could jeopardise the mother, where, for example, she might develop overwhelming infection, uncontrollable blood pressure, seizures or life-threatening bleeding, we would have no option but to terminate the pregnancy or, depending on the gestation, deliver the baby pre-term. We work very hard with the family and each other to promote foetal viability in order that the baby will get to a stage where it can survive. After the baby is born, intensive care would be offered. if medically appropriate. That is current standard medical practice.

Deputy Billy Kelleher also asked whether we had capacity for this Bill. To reiterate, we are talking about rare medical disorders and small numbers of cases. We already look after such cases. The Bill merely provides a legal framework for our current clinical practice. I do not anticipate large numbers of patients suddenly becoming suitable for these procedures where previously we have seen only very small numbers. However, it is important to note that we have approximately half the number of obstetricians per head of population in Ireland as there are in the United Kingdom; therefore, we are dreadfully under-resourced and would welcome improved resourcing.

Deputy Caoimhghín Ó Caoláin asked how many obstetricians would be required to examine the patient. Again, we are talking about complex medical disorders where multidisciplinary teams are required. In current medical practice it is often the case that more than one obstetrician would assess such a patient in order to achieve a consensus view. However, if a colleague felt there was no option but to terminate the pregnancy, we are not saying two obstetricians would be required to examine the patient but that a second obstetrical opinion be sought just to underpin the approach. In complex cases such as these there is always consultation with more than one person and often with a very large team. We would want the obstetrician who examines the patient to seek support, which could be in the form of a telephone conversation, for instance, or a case review. We are totally supportive of patient confidentiality at all times and there would no difference in such cases.

In regard to head 3, the Bill refers to a health facility and talks about locations other than those recognised. We are concerned that emergency treatment should only be offered in a hospital setting, not in a clinic or an outpatient setting such as a GP's surgery. These are emergency life-saving procedures and it is our view that they should only be carried out in a hospital setting.

The specialist division of obstetrics and gynaecology came into being in 2005 or thereabouts. Consultants appointed prior to that time will be on the general medical register but may not be in the specialist division. This means that a number of very experienced consultants who are very capable of making patient assessments are not in the specialist division. For this reason, we have asked that the provision be expanded to include an obstetrician or gynaecologist acting in the consultant role who is in the general division only. Otherwise, the concern is that patients who present requiring emergency treatment might not be able to receive it if the consultant who sees them is not on the specialist register. This is an historic issue that will be resolved over time. In the meantime, however, we have several experienced obstetricians who are not on the specialist register.

In terms of notification of cases, we are totally supportive of the requirement for audit and documentation. In fact, within our own hospitals these cases are already recorded and discussed. I suggest this matter is best dealt with in guidelines, with these unusual cases being reviewed, say, on an annual basis. Members may be aware that the National Perinatal Epidemiology Centre is collecting data on cases of severe maternal morbidity. This means that many of the cases are already captured in a national context.

Deputy Seamus Healy referred to the provisions regarding appropriate locations. In our previous submission we explained in detail that we were talking about patients who were medically very unwell and needed access to specialist physicians, coronary care units and intensive care units. Many of our maternity units are not co-located. The units in the three Dublin maternity hospitals and one in Limerick, for example, are stand-alone units. The patients to whom we are referring are usually cared for in hospitals with a general intensive care unit and coronary care unit. It is imperative, therefore, that general hospitals are able to carry out these procedures. That is where these patients will be treated because they are too ill to be looked after in a stand-alone maternity unit.

The Deputy also asked about the availability of personnel throughout the country. There are 19 maternity units in this country providing high quality maternity care. They are also providing emergency care, which would include termination of pregnancy. That is current practice. What the legislation does is put a framework around it.

I will defer to my colleague, Dr. Méabh Ní Bhuinneáin, to provide detail on the smaller units.