Dr. Peter Boylan:

I will not go any further into the 20 week scan issue as it has been addressed fully by Professor Kenny.

With regard to neural tube defects and folic acid supplementation, the easiest way of getting around that is to supplement food on a nationwide basis. Education is essential and to be recommended but it will not work. We should supplement food in the same way that we put fluoride in the water, which helps our teeth. I do not see any problem with it, apart from objections by some people who will object to everything, including vaccines and so on. We should just go ahead and put the folic acid into the food.

With regard to the separation of the baby from the mother at birth when the baby has an anomaly that needs intensive care, the programme, which is the only one I can speak about but I am sure the position is the same in Cork and in the other Dublin maternity hospitals, is that conferences are held on a weekly basis attended by paediatricians and obstetricians. We get consultants in from the children's hospitals on a regular basis to discuss particular problems that have been identified. The parents meet the paediatricians or the surgeons afterwards so that there is a plan for the delivery. They have met the surgeon who will operate on their baby after its born and the paediatrician who will look after the baby. That would help in that respect.

Where diagnoses are made for women who live in more rural areas or distances from Dublin, those women will be transferred to Dublin for consultation or to Cork in the southern area. They would attend regularly and a decision is then made on the most appropriate place for them to deliver. It is almost always in the major unit so that they can have easy access to care afterwards by the paediatricians and-or the surgeons.

With regard to home births and breastfeeding, if we consider social grading or class, to use that word, and education levels, home births are much commoner among highly educated women who tend to breastfeed more. There may be a correlation with that and as the Deputy said, there is more of a buy-in to the whole birthing experience and so on. The low rates among Irish women are probably cultural in nature and it will take a long time for that to be addressed sufficiently. There is a hangover effect in that regard. We have addressed the issue of mother and baby units, the separation aspect and those women who have puerperal psychosis or severe mental breakdowns in the post-natal period.

To address Deputy Durkan's issue regarding data protection, I am not sure that it has any influence whatsoever. The doctor-patient relationship is an extremely confidential one. By virtue of our ethos, guidelines and practice we are not allowed discuss patients outside the arena of the clinical world. It is a very serious issue to break confidentiality in regard to patients in any way whatsoever.

In terms of what needs to be done to implement the maternity strategy, a few things can be done. I agree entirely with the aim that we need to introduce more community midwifery. The Domino scheme is a very good example. Community clinics are run by midwives closer to the mothers' homes so that they do not have to travel to the clinic where they spend no more than five or ten minutes, get on the bus and go home. It is much better to have those closer to them.

With regard to the mastership model and jobs, it is interesting that where a job is solely in one of the Dublin maternity hospitals and not linked to another hospital there does not seem to be any huge difficulty in filling those posts. That is because they are working under the governance of the mastership model where they know there is a clinician in charge whom they can talk to, who will understand what they are saying and will allocate resources in the best interests of patients attending the hospital.

No matter how well intentioned a manager is who is not medically qualified, and they are well intentioned, they can never fully understand the business because they are not dealing with difficult cases at 4 o'clock in the morning. They are not dealing with all the clinical problems. They are not on the wards understanding the clinical issues. It is important that managers are there to back up the clinicians in the mastership model.

Many people have an objection to the word "master". It is a clearly identifiable term. Everybody knows what it is. The captain of a ship is the master of a ship. There is no difficulty with that. We need to get over any difficulties we have with the name. We should accept it. It is recognised, and it works.

The Minister said recently that he would fire managers who were not performing adequately. We will wait with great interest to see whether he follow through on that statement. If he really means what he says, we will see the actions taking place but we will be watching with great interest. I will not make any reference to the Skibbereen Eagle because it might be taken up inappropriately.

A question was asked about the minimum size of a maternity unit. It is an interesting question because it depends on the level of complexity of care. Where there is any issue about a complication, it is clear that care must be in a large unit where there are people with the experience who will not become deskilled by not dealing with problems on a regular basis. Currently, when problems are identified, most of those women will be referred to one of the larger centres in Galway, Cork, Limerick or one of the hospitals in Dublin. That is the way it works.

One of the problems with obstetrics is that events can happen in a completely unpredictable way. That is one of the difficulties many doctors would have with regard to home births. There is a well recognised reluctance on the part of many doctors to encourage or even accept the concept of home births. That is due to their experience of the sudden catastrophic event that can happen.

Perinatal mortality rates are very low in Ireland, and they are very low among home births, so we would need to have thousands of births to see a pattern. The unfortunate truth is that where studies have been done either in this country or internationally, the perinatal mortality rate - the death of babies - is higher among home births. My personal feeling about it, having worked in a hospital which has a home birth service and having observed some of the problems that happened in home births, is that mothers having their first babies should have their baby in hospital because it is among those births where the greatest problems arise, and sometimes completely unpredictably. The Domino scheme would be a very good compromise for mothers who want to have a home birth on their first baby. They have all of their care outside the hospital. They come in for scans and so on. They come in and have the baby and then go home within a few hours where their community midwife looks after them. That is the same team of community midwives who looked after them in labour so they have continuity of care and the closest they can get to a home birth without any of the risk associated with it.

For mothers who have had a successful first birth without any difficulties, home birth is perfectly safe on second and subsequent births unless well recognised problems arise. They are less likely to have any problems. The institute would give a qualified support for home birth services but recognises that there are risks associated with them. It is extremely unlikely that an individual woman will encounter such a risk because the rates are so low, but it is an unavoidable tragedy when these events sometimes happen. That is not to say that there are not unavoidable tragedies happening in the hospitals. That has to be admitted. There is no question about that.

If the committee wants to consider one measure that is cheap - it would not cost anything - and would improve services, it would be to change the governance models, which implies changing to the mastership model.

Much attention has been focused on Cork in recent times. Why not do an experiment in Cork involving implementing the mastership model, reviewing it after a few years to identify whether it is working and is more successful than the current model in regard to waiting lists for gynaecology, etc., and if it is shown to work as well as it does in Dublin, where it clearly works, implement it nationwide?