Professor Sabaratnam Arulkumaran:

I wish to express, to Senator Noone and respected members of the Oireachtas Joint Committee on the Eighth Amendment of the Constitution, my sincere thanks for providing me the opportunity to give evidence on the important issue of reviewing the eighth amendment of the Constitution of the Republic of Ireland.

The issue is linked to the sexual and reproductive health and rights of women, the subject on which I have worked for decades as a women's health physician and in my capacity as past president of the Royal College of Obstetricians and Gynaecologists, the British Medical Association and of the International Federation of Gynecology and Obstetrics.

For today, I was specifically asked to focus on the particular concern to the committee which is the issue of the risk to the health of the mother including her physical health, which the Citizens' Assembly refers to in its recommendations 3, 5, 6 and 8.Please permit me to start with some general remarks that will be followed by my answers to the specific issues.

First, I congratulate and praise the maternity care in the Republic of Ireland that has had a very low maternal mortality ratio for years and is ranked sixth in the whole world, as shown in a graph that I have included in my presentation to the committee.

Details of these few deaths are always analysed by the Irish obstetricians. A confidential inquiry into maternal deaths in Ireland indicates nearly half are due to indirect deaths, not related to pregnancy but due to cardiac and psychiatric conditions and so forth. This is of some relevance to the issue under discussion. The detailed report on the confidential inquiries is included and referenced in my statement.

I greatly appreciate the first report and recommendations of the Citizens' Assembly on the eighth amendment of the Constitution, published on 29 June 2017. I commend the Citizens' Assembly on its work. The report is an impressive achievement by people who are not health care specialists or experts, but spent five weekends considering the issues. The members of the Citizens' Assembly voted on their recommendations for access to abortion for certain medical and other conditions. Members are, of course, familiar with the results of the ballots and these can be viewed in the report.

I would like members to consider the opposite side of the coin and if the same questions were asked such as: "Would you send the women who procured abortion for these reasons to prison?" A research project in Brazil led by the eminent obstetrician and gynaecologist, Professor Anibal Faundes, surveyed 1,660 civil servants and 874 medical students. They were asked two different questions: first, under what circumstances should abortion be allowed under law; and, second, if they agreed that women who had abortions outside the law should be imprisoned. The research concluded that Brazilians have different views on when abortion should be legal, but most do not agree with imprisoning women for abortion. Hence I urge parliamentarians, the newspapers and the public to take that into consideration and ask the question as to whether they would wish to imprison women who procure abortion. A law that allows abortion for only certain minimum grounds mandates the imprisonment of women who have abortions under all other grounds. I think members would find that this is not what the public wants, neither in law nor in practice.

I shall now give my views on the specific health issues that were raised in the Citizens' Assembly report and other health issues that were not raised but are of relevance to the eighth amendment of the Constitution. First, abortion is life saving in certain health conditions, for example, a mother with chorioamnionitis and severe sepsis, pre-existing severe heart disease, and poor mental health and a threat to commit suicide. There are examples of such incidents from the Republic of Ireland. Deaths from these conditions occur due to the difficulty in assessing that the seriousness of the condition meets the legal criteria of "real and substantial risk" that can only be averted by ending the pregnancy, and the fear of legal punishment that prevents a doctor from taking a firm and early decision.

Abortion in certain health conditions will avoid deterioration of health, for example, cardiac, renal, and neurological conditions. We could formulate a list of conditions but we will not be able to cover all the different conditions and combinations of conditions that we encounter as clinicians. Each mother needs to be individually assessed as to whether the condition is serious enough to terminate a pregnancy. Such lists are used in certain countries where restrictive abortion laws operate. However, mothers slip through the net and end up with worse organ damage. A list of the medical conditions that are considered serious enough to terminate a pregnancy in Peru include hyperemesis gravidarum refractory to treatment with severe hepatic and-or renal impairment; malignant neoplasm requiring surgical treatment, radiotherapy and-or chemotherapy; functional class III or IV cardiac failure; severe chronic arterial hypertension and evidence of organ damage; systemic lupus erythematosus with severe renal damage refractory to treatment; advanced diabetes mellitus with vital organ damage; and severe respiratory failure demonstrated by certain parameters. The Peruvian document is included in the references.

The errors due to conservative management of continuation of pregnancy compromise the mother's health with further deterioration of organ function that leads to shorter life span and at times death. Such incidents are greater in the countries with restrictive abortion laws and are due to fears by the doctors of facing legal action. An article showing an example of such deterioration involving a cardiac condition is included in the references.

Abortion under optimal conditions has less maternal mortality in developed countries compared with continuation of pregnancy. It is 0.7 per 100,0000 with safe abortion care compared with ten per 100,0000 with continuation of pregnancy. These are due to life threatening complications such as thromboembolism, hypertensive disease, postpartum haemorrhage, amniotic fluid embolism, and so forth as referenced in WHO document.

In the United Kingdom, approximately 190,000 abortions are carried out each year and there were only two recorded maternal deaths in the five years from 2012 to 2016. The statistics of UK abortions are referenced. The clear majority of abortions were done under clause C, that is, that "the pregnancy has not exceeded its twenty-fourth week and that the continuance of the pregnancy would involve risks greater than if the pregnancy were terminated" of injury to the physical or mental health of the pregnant woman mainly on grounds of further deterioration of mental health.

Abortion is not associated with physical or mental health hazards to the mother and it has no impact on future pregnancies. This has been made clear by the statement of the Royal College of Obstetricians and Gynaecologists and is included in appendix 1.

Abortion should be permitted for lethal foetal malformation and severe congenital malformation that may have a major impact on life. This is also the position of the Royal College of Obstetricians and Gynaecologist and is included in appendix 2.

Safe abortion care should be consider as a public health and human rights issue. Despite good contraceptive coverage, about 10% of women get pregnant and seek abortion. In countries where abortion is legalised, the total abortion rates and maternal mortality have declined due to safe post-abortion care and post-abortion contraception.

Making abortion illegal has not stopped illegal abortion for centuries and in different countries. It increases maternal mortality, and this is referenced. About 4,800 women in Ireland have their abortions done in the United Kingdom. These are the reduced figures as the numbers have reduced by 20% in the past year or so due to availability of medication by post for self-procuring abortion. These have their own complications.

Abortion is a sexual and reproductive rights issue and the decision should be made by individual women after adequate information is given. If abortion is not made legal, it will promote illegal abortion. Those women with influence and financial resources will get it performed in a safe environment. Those who are poor with less influence will resort to unsafe abortions. This would be a social injustice.

I shall conclude with a few extracts from some of the world bodies. The WHO states that "abortions and the high maternal and child mortality rates constitute a serious public health problem in many countries". It continues:

Criminal laws penalising and restricting induced abortion are the paradigmatic examples of impermissible barriers to the realisation of women's right to health and must be eliminated. These laws infringe women's dignity and autonomy by severely restricting decision-making by women in respect of their sexual and reproductive health.

The report of the UN special rapporteur on the right to health to the UN General Assembly in 2011 stated: "Certain criminal laws effectively shift the burden of realising the right to health away from States onto pregnant women, punishing women for the lack of effective provision of health-care goods, services and education by the Government."

Ireland can and should provide first class sexual and reproductive health based on rights and public health perspectives. There are minimal ill effects to health with a well-informed safe abortion. This is from the Royal College of Obstetricians and Gynaecologists, appendix 4. Health advantages of avoiding or not having unwanted pregnancy need to be considered in addition to specific socio-cultural issues faced by the women.

The excellent maternal mortality rates in Ireland as number six in the world may become 20th or 40th in the world if legal access to abortion is denied to the 4,800 women who may not be able to go to the United Kingdom, but may procure illegal abortions. At any cost, we must avoid having illegal abortion. I thank the Chairman and members for considering my submission statement.