Professor Louise Kenny:

Taking those issues in turn I will address first the issue of consultant attraction and retention. Notwithstanding the fact that we need to attract another 100 consultants to bring us up to international norms, even that will still be at the lower number of comparable consultants per 1,000 live births in the OECD countries. It is going to be a challenge. In Cork we do not even have the jobs to recruit two, but even if we did it would be a challenge because of the issues I outlined in my statement. It takes 12 to 14 years to train a subspecialist in obstetrics and gynaecology. That is not a quick process. What is perceived as a very hostile media, allied to a very unattractive consultant contract, means that at every stage of training our trainee specialists are now leaving the State in significant numbers. Ireland is failing to attract trainees in at an early stage upon leaving medical school. At every stage they are leaving for other countries, for better working conditions, greater parity of pay and better working hours. That is a significant issue for us. We know - because we have a very transparent and robust reporting system - that our clinical outcomes for mothers and babies are comparable with the best internationally. There is some variation in figures and population differences can sometimes mask inequalities of caseloading, but that is despite the fact that our clinical resources are inadequate. That is reflective of the very high standard of midwifery care and consultant care in this State. It is not, however, sustainable for much longer. Senator Burke spoke about the straw that broke the camel's back and we are approaching that point.

On the ultrasound issue, in Cork less than half the women are able to access the 20 week scan. A few years ago that figure was slightly better but loss of staff and the fact that we have not been able to replace those specialist staff has led to the provision of the 20-22 week scan only being available to that half - or less - of the women attending our unit. I can give the committee some anecdotal evidence of the impact of this situation. Women in Cork are two and a half hours by road from Dublin and if a baby is born with hypoplastic left heart syndrome it needs to be assessed immediately after birth and transferred to specialist services. If that baby has not been identified prior to birth due to lack of the 20-22 week scan that whole process has to take place ex-utero with a very critically ill baby in an ambulance.

This is the most disadvantaged start that child can have and it will absolutely have an impact on its chances of survival. It is a devastating event for a family. Other anecdotes involve significant foetal abnormalities such as anencephaly, a very severe form of spina bifida. If it is not diagnosed antenatally, the effect it can have on health care providers and the women in question is unacceptable in 2017.

There is no way we can triage or screen for risks in the case of the 22 week scan. Because we cannot offer a scan to everybody in Cork, we triage on the basis of age and previous history. It is a screening test but for it to work, it must be applied across the entire population. Clinicians who make the decisions about who should and should not have a scan are haunted. It is both extremely frustrating and unacceptable.

There are time issues with the 20 to 22 week scan. The staff in our unit are highly skilled midwives. It take many years to be trained in midwifery and ultrasound provision. The staff are involved in post-diagnosis management and counselling. If we were to roll out the service tomorrow, we would not be able to match it with adequate foetal medicine services because we would detect a significant increase in the number of abnormalities which would require specialist input. Nothing can be done in isolation. Our big concern is that if we were to address any one of these inadequacies, it would have to be done in tandem with the rest of the strategy.

The budget for women's health services is still the first to be cut in 2017. That is both self-evident and a fact. Historically, there are a few reasons there are unacceptable waiting lists, which are national disgrace, but it is mainly down to governance. In obstetrics we often say we fire fight. We cannot say "No." We cannot let a waiting list build. Babies will come at 2 a.m. and 2 p.m. and the obstetric service manages in this fashion.

Most women who are significantly ill with gynaecological diseases do not lie on hospital trolleys. Generally, they are young or middle-aged women who do not present at emergency departments. They do not lie on trolleys and are not part of the trolley initiative. They are not on anyone's radar.

With regard to the impact of gynaecological conditions on women's lives, more than 4,000 women are waiting to be seen in outpatient services at Cork University Maternity Hospital. Many of them are incubating a malignancy, which is an unacceptable level of risk. Those who present with urogynaecological issues or heavy menstrual bleeding are young women who are trying to raise a family and-or hold down a job, have a haemoglobin level of five and bleed two or three weeks every month. They cannot leave the house. They are housebound for the want of an outpatients service treatment investigation and effective management. From a urogynaecological perspective, we have women who suffer from urinary incontinence. It has been well demonstrated in a lot of international research that this has the most devastating psychological impact on a woman's health and well-being. It has a significant impact on the household's economy as women cannot work and are on long-term sick leave. It has an impact on their children and partners. It is a devastating conveyor belt towards significant problems. Frustratingly, many of these issues can be addressed adequately. We are not speaking about very complex open-heart surgery but about access to relatively low intensity procedures. If we were resourced adequately, we could offer them. I come back to the fact that many women who are referred to the outpatients service with what are perceived to be minor problems, because we can only triage on the basis of a referral letter, are incubating a malignancy, which is an unacceptable level of risk.

I will be happy to answer supplementary questions or go into any of these issues in further detail.