Dr. John Monaghan:

On that question, one would have to separate the physical illness from the psychiatric component. With physical illness, one may be forced to deliver the baby because one has to do it. Simply, the baby could be born at 20 to 24 weeks; it has to be done. The psychiatric component is unknown. The question has arisen as to whether one could care for the woman until the baby had reached a certain stage of viability. It has been suggested if a child is delivered at 23 or 24 weeks and survives, because of the age at which it is delivered, it is significantly more likely to be handicapped by cerebral palsy or blindness or suffer from another serious life-long disability. I could not say anything more than that on that question.

On the real and substantial risk and the obstetrical element of impending serious maternal illness, an experienced clinician knows a real and substantial risk. Decisions on the medical complications involving cardiology, cancer, etc. are often multidisciplinary and an experienced clinician would know the answer intuitively. The only question to which the answer is unknown is that of suicide. I cannot comment on it.

Deputy Denis Naughten referred to the subhead on obstetric and maternal health and the closure of a psychiatric unit. I would not be able to tell whether the closure of a unit in Roscommon, for example, would affect the unit in Ballinasloe or vice versa in terms of the availability of services. There is a centralising tendency within the HSE and, in the past 15 or 20 years, hospitals have gradually been run down. Dundalk, Monaghan and Roscommon are examples. I do not know what the effect from a psychiatric point of view would be. As I said, I am not a psychiatrist. If a problem proves to be an important medical one, the nearer the psychiatric help is to an obstetrical unit, the better. The question on appropriate locations and the removal of smaller units was the same.

Senator John Crown asked about maternal mortality, which he said was exceptionally rare. It is clear that the rate of maternal mortality is rising and has been for approximately the past ten years in the United Kingdom, Denmark, Canada and the United States. There is little evidence that it has risen in Ireland, but I do not think we can tell as yet. There are multiple reasons for the trend. The major one in the United Kingdom has been sepsis, or infection, in addition to increasing maternal age and higher rates of multiple pregnancy. There are many reasons. One component may be training and the care of pregnant women.

On the question about it being sudden or not sudden, it is correct to say many situations of termination of pregnancy in a rural unit would arise on a Sunday afternoon when somebody arrives in suddenly having seizures, in which case the baby has to be delivered immediately. Regarding whether one can extrapolate from this to take in the suicide question, I am not going to answer and I am not capable of answering. As I stated, it is a matter of grave concern to me.

Consider the question of having a right to conscience in a smaller department or rural unit. As I said, there is no evidence that conscientious objection has led to any maternal death. Senator Jim Walsh asked about the case in Galway. Certainly, there was no mention of the word “conscience” in the inquest report, which I read.