Professor Louise Kenny:

To answer Senator Colm Burke's question on consultant staffing levels in Ireland, as per our previous submission to this committee, the number of consultant obstetricians and gynaecologists in Ireland is the lowest in the top OECD countries, at 3.95 per 1,000 live births. Ireland has a high birth rate, so the number is even lower when corrected for birth rate. Dr. Boylan will speak more on this, but it is estimated by the Institute of Obstetricians and Gynaecologists that we need to appoint another 100 consultants to bring Ireland up to anything like international norms. As for whether we have sufficient capacity in the system at the moment, it is well-known that Ireland trains some of the best doctors in the world. Those doctors currently staff the units of Australia, New Zealand, the UK, Canada and America. We would love to bring some of our trainees home. Currently, they will not come home because of divisive contract, because the working conditions here are appalling and because they are better serviced in other countries. We believe we would have capacity to increase consultant numbers over the next five years in a phased way. I do not think anyone would favour suddenly creating 100 posts because we do not have 100 high quality trainees to fill those posts at the moment. However, a phased recruitment strategy would be very welcome.

In answer to the question on anatomy scans, I do not think there is one solution that will fit all units as the problems vary. I would strongly argue that this is not an unfixable problem. Ireland does not need to find expensive and scarce radiographers, who are not plentiful here. Midwives can be trained to a standard sufficient to perform foetal anomaly scanning. There is a recognised diploma in Dublin which takes two years, but within three months of commencing that training midwives on the course can perform routine first trimester scans. In a unit like mine, this would free up other specialist individuals who could then perform the anomaly scans. If there were backfill for the people in our units who have completed training, and a few extra midwives could be trained, it would be possible to fix the situation in our unit within six months. That is not the case in some other units, where lack of equipment and lack of personnel are more problematic. Nevertheless, significant inroads into this problem could be made in a very short period of time. It is not unfixable.

Pre-conception care means different things to different people. I provide a pre-conception care service for women with complex medical issues who are contemplating pregnancy. It is very beneficial for women who, for example, have epilepsy and are on complicated medical regimes, or women who have diabetes. This is not uniformly available across the country; I think it is only available in the big units. Increasing problems with obesity and older maternal age are significant public health issues. An increase in availability of pre-conception care would be welcomed, but it would require significant resource allocation. As an obstetrician, a gynaecologist and a mother, I completely agree that fertility should be part of the package of care that is provided. It is flagged within the national maternity strategy.

Returning to Deputy O'Reilly's question about whether an anomaly scan is clinically indicated, that is exactly the point in question. This is a screening test and it should be uniformly available to everybody who wants it. I make decisions on a daily basis as to who should receive this scan and who should not and it results in foetal abnormalities being missed in women who are perceived to be at low risk. The vast majority of abnormalities occur in low risk pregnancies.

Equipment is not the fundamental barrier to routine access. Admittedly, the equipment is specialised, expensive and has a shelf life, but it is not, in my experience, a barrier. There are staff training issues but, as I previously discussed, we have the capacity to train midwives to a very high standard to perform this service.

In my unit at the moment we cannot release those midwives from other clinical areas. If we were to release them, their positions would not be backfilled. We also have three midwives who have completed the course and who can function as very highly-trained midwife sonographers. However, their qualification has not been recognised, they have not been moved up to the clinical nurse manager 2 grade and they are not being remunerated for that work. As a result, they are staying within the clinical service. We have the capacity to change the system, but not the power to do so.

I do not think there is an ethos that is providing a barrier to provision of the 20-week anatomy scan. This scan detects often treatable abnormalities, and facilitates better delivery care planning. I do not believe anyone in Ireland currently is not having this scan because of a pervading ethos. That question is pertinent for first trimester screening. The UK is now moving towards routine non-invasive pre-natal testing, which is a very safe and highly effective way of screening for foetal abnormality in the first trimester. The routine roll-out of first trimester screening might come across a barrier of ethos. However, we are many years away from being able to consider the provision of that service when we still cannot routinely offer 20-week anatomy scans.

Breast-feeding initiation rates are going up in Ireland, which is very pleasing for anyone involved in this area to see. Initiation is one thing; maintenance at two months or three months post-delivery is quite something else. Speaking as a mother rather than a doctor, the fundamental barrier to breast-feeding is our lack of ability to provide post-natal care in the community. I had my children in the UK. During my first pregnancy I was visited by a midwife on a daily basis for two weeks, and that was critical to me being able to establish breast-feeding. We do not have that service in Ireland, and I think that is the number one barrier to maintenance of breast-feeding.