Dr. Sam Coulter-Smith:

It, therefore, creates an ethical dilemma for any obstetrician who has requested to perform a termination of pregnancy for the treatment of someone with either suicidal ideation or intent. Third, this legislation, I am sure, is designed to create clarity and reassurance for both health professionals and patients alike.

The fact that there is no gestational limit in respect of the third scenario relating to suicidality is a major ethical issue for obstetricians. I will illustrate this with two scenarios. First, let us consider the case of a patient who is 25 weeks' gestation. If she is deemed to be sufficiently suicidal to require a termination of pregnancy by one or more psychiatric colleagues, an obstetrician who is tasked with dealing with this situation is faced with an enormous ethical dilemma. Delivering a baby at 25 weeks' gestation could lead to death, due to extreme prematurity or it could lead to a child with cerebral palsy or with other significant developmental issues for the future. This outcome would be entirely iatrogenic and the responsibility of those clinicians who have agreed to be involved in the process. This is a source of serious concern for myself and my colleagues.

Another clinical scenario which provides a difficult ethical dilemma is a situation whereby at a woman's 20 week anatomy scan a significant but non-lethal malformation is discovered. The patient, for a variety of reasons, may decide that she cannot continue with the pregnancy and it is causing her significant mental health issues with risk of suicide. The obstetrician is left in the unenviable position of, by law, having to look after the best interests of the baby but also the understanding of the mother's issues. It would, therefore, seem appropriate in a case where there is a risk of self-destruction that there is no gestational limit applied in this situation as this creates a major ethical dilemma for us.

My overriding concern, however, in relation to the whole area of self-destruction and termination of pregnancy to prevent same, relates to the lack of evidence to show that termination is of any assistance in this scenario and that we as obstetricians and gynaecologists must be able to stand over the decisions we make as being based on good medical evidence.

In relation to the infrastructure and resources it is my view, and that of many of my colleagues, that the inclusion of suicidality within the legislation may, and I stress may, in the long term lead to an increased demand for termination in this country. We currently do not have any real understanding of how big that demand may be. Currently in excess of 5,000 women a year go from Ireland to the UK to have termination procedures performed. We cannot be certain how many of these women would decide to use this current legislation as a means of obtaining a termination in this country and even if unsuccessful in obtaining a termination in this country, a huge amount of time and resources will be spent on the assessment of these patients.

We currently have three sub-specialist psychiatrists with a special interest in mental health issues in pregnancy. These are part-time posts attached to each of the three Dublin maternity hospitals. Mental health issues in pregnancy are among the most common complications we see, affecting between 10% and 15% of our pregnant population. The impact of this very high incidence of mental health complications means that these services are overstretched and find it difficult to cope with their existing workload. Any increase in the workload of these services could put huge strain on the system and take it beyond breaking point.

Each of our Dublin maternity hospitals delivers approximately 9,000 women per year. The midwife to patient ratio is approximately half of what it should be, the consultant to patient ratio is also half of what it should be. We have seen an increase in the delivery rate in Dublin of about 30% over the past six years and this has put an enormous strain on the infrastructure of our hospitals. The increase in the number of women delivered is now leading to a huge increase in the demand for gynaecology services to the extent that waiting lists for routine gynaecology outpatient clinics are currently well over a year and growing. The combination of these factors means that it would be extremely difficult for us in the maternity hospitals to take on any additional service which would require input from staff in an outpatient setting in terms of assessment or in theatre time to cope with an increase in the number of termination procedures.

In conclusion, I welcome this draft legislation, particularly in the area of real and substantial risk to the life of the mother which pertains to physical illness. I think, however, that there are significant concerns in all areas of the medical profession in relation to this Bill when it comes to suicidality. Our overriding concern relates to the lack of evidence to show that termination of pregnancy is an appropriate treatment for women who are deemed to be at risk of suicide. As obstetricians we are expected to practise evidence-based interventions and first and foremost to do no harm. This legislation should help in providing clarity and reassurance to professionals and patients alike. To enact and underpin the idea that termination of pregnancy is a solution or a treatment for a patient at risk of committing suicide when there is no evidence to support that intervention creates an ethical dilemma for our profession.

To make matters a little more difficult there is no gestational limit mentioned in the draft at which this termination might happen. This opens the possibility for iatrogenic prematurity with all the risks of infant morbidity and mortality. Who will be responsible for these interventions? I also confirm to the committee that we as a profession, and particularly in my hospital, have concerns about the potential for increased demand for termination services in this country as this may be an unintended consequence of this legislation in its current form.