I welcome everybody to our session. I remind members, witnesses, Members in the Gallery and media that mobile phones should be turned off for the duration of the hearings as they interfere with the recording of proceedings.

You all are welcome to the session. This is the fourth session in our series of hearings that the joint committee is conducting over three days to discuss the implementation of the Government decision following the recent publication of the expert group report into matters relating to A, B and C v. Ireland. In that regard, I welcome the following: from the Irish Family Planning Association, Mr. Niall Behan, chief executive; from the Institute of Obstetricians and Gynaecologists, Professor Robert Harrison, chairman, Dr. Meabh Ní Bhuinneáin and Professor Fionnuala McAuliffe; and from Maternal Death Enquiry Ireland, Professor Richard Greene. I also welcome Dr. Caitriona Henchion, medical director of the Irish Family Planning Association.

I remind witnesses that they are protected by absolute privilege in respect of the evidence they are to give to the committee. However, if they are directed by the committee to cease giving evidence on a particular matter and continue to so do, they are entitled thereafter to only qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against a person or persons or an entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing parliamentary practice and ruling of the Chair to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official by name or in such a way as to make him or her identifiable.

I again welcome Mr. Niall Behan and ask him to make his opening remarks. He has ten minutes.

The Irish Family Planning Association is glad of the opportunity to assist the committee on this important issue. The IFPA, as we are probably better known, provides medical services to in excess of 20,000 clients per year. Those are mainly contraceptive services and family planning services but also treatment for sexually transmitted infections and post-abortion care. Through our national network of pregnancy counselling services we provide information and support to almost 5,000 women and girls experiencing crisis pregnancies that were unplanned or unwanted, or developed into a crisis because of changed circumstances.

Women use our services because they feel they are not currently in a position to care for a child or, very often, another child. Their reasons include financial worries, diagnosis of a serious foetal abnormality, a pre-existing health problem or relationship issues, or sometimes a combination of all of those issues.

The IFPA knows from its counselling service that women who choose abortion are from all walks of life and each woman has her own reasons for deciding to have an abortion. Women's experiences of abortion are diverse and complex and the decision to have an abortion is not one that women take lightly.

The experience of the IFPA and of many doctors is that medical service providers in Ireland are prevented from acting in the best interests of pregnant women's health at some points, and must navigate some grey areas of law to protect themselves and patients from prosecution. As a service provider, therefore, the IFPA very much welcomes the Government's decision to implement the judgment of the European Court of Human Rights in A, B and C v. Ireland.

Very few of the women who avail of our service do so because of risk to their lives, but some women do. The women who come to the IFPA in life-threatening circumstances tend to present at a very early stage of pregnancy before the risk is imminent and with our services, we are not talking about emergency situations. They tend to be women who have had serious complications during previous pregnancies or who have underlying health conditions, and usually they have been advised at some point previously not to become pregnant or that becoming pregnant again could impact on their health. For example, applicant C in A, B and C v. Ireland was six weeks pregnant when she realised that she had difficulties. These women have taken a decision to terminate the pregnancy rather than incur a risk to their lives or to their health. They are not prepared to wait until the risk to their health deteriorates to such an extent that it becomes a risk to their life.

The serious risk posed to a pregnant woman's health can be for a range of reasons, including heart issues, kidney diseases, oncology, neurology, gynaecology, obstetrics and a range of genetic conditions. The pregnancy may exacerbate the risk to women of a pre-existing condition, for example, epilepsy, diabetes, cardiac disease, some auto-immune conditions and severe mental illness.

The case may be that there is a risk to a woman's health rather than to her life. From our perspective as a medical services provider, it is very difficult. We do not see any kind of bright line distinguishing between a women's life and her health. Indeed, no other country in Europe forces doctors or medical services to make the distinction that is made in Irish law where abortion is only allowed to save a woman's life, but not to preserve her health. Most countries offer abortion on the basis of the adverse consequences for women's health as the only way to ensure that a full range of sexual and reproductive health services are available to her.

For women in these circumstances the burden of accessing abortion services is placed on the woman rather than on the health care system, and that is an important distinction to make. Women who make the journey to the United Kingdom for medical reasons do so in the context of legal uncertainty. There is a chilling effect in the current law and the standard medical referral protocols may not be applied. Women in this context must leave the mainstream health-care service. They must make their own way to a private medical facility in another country without the protection of the protocols that apply in other situations. While some doctors make ad hoc arrangements, we know of women who have travelled without medical files detailing their medical history or proper referral from a doctor.

These women travel outside the State to avail of services that are criminalised in Ireland, a journey that in many cases involves significant psychological, physical and financial burden - a burden that was recognised by the European Court of Human Rights. These burdens fall most heavily on those who are already disadvantaged or vulnerable, namely, those with little or no income, women with care responsibilities, women with disabilities, women with mental illness, women who experience violence, young women and women requiring travel visas.

It is critical that medical service providers and, indeed, the women themselves can rest assured that accessible and appropriate services will be put in place and that women can be confident that their decisions will be respected and free from discrimination, coercion and stigma, and that their rights will be fully vindicated.

In that regard, the legislation and guidelines must not be so complex as to render them ineffective in practice. As the European Court of Human Rights has stated, they cannot be theoretical and illusory. The Government must be guided by the expert group's unambiguous direction so that the potential options are effective and accessible. The expert group considered it insufficient for the State to interpret the court's judgment as requiring only a procedure to establish entitlement to termination without also giving access to such treatment. In this regard, I am heartened by the discussions today that have focused on the barriers that may arise, such as conscientious objection, refusal to care and capacity to provide services.

In regard to the threat to life by suicide, the IFPA has dealt with clients who have had suicidal thoughts or threatened suicide. A small number of individuals followed through on these threats by taking overdoses. The expert group gave extensive consideration to the appropriate legislative and health service response to the risk to life by threat of suicide and the IFPA welcomes the clarification by the export group report that a termination of pregnancy is lawful medical treatment regardless of whether the risk to life arises on physical or mental health grounds. The expert group's approach would place suicidal intent in the context of pregnancy and existing health services without stigmatising either mental health or a termination of pregnancy.

The final issue I wish to raise is criminalisation of abortion. It is clear from the expert group report that the legislation implementing the A, B and C judgment must remove sections 58 and 59 of the Offences Against the Person Act 1861. We understand that some Members of the Oireachtas may be concerned that legislating this way where a pregnant woman's life is at risk might lead to an increase in abortion rates. From the thousands of women we have seen over the years, it is our opinion that criminalisation of abortion does not deter women from seeking termination or lead to lower abortion rates. It has been the IFPA's experience that when a client decides to terminate her pregnancy she has made her decision rationally and is unlikely to change it regardless of the legal obstacles in her way. Her focus quickly shifts to the practicalities of organising and financing the procedure in another country.

I call Professor Richard Greene from Maternal Death Enquiry Ireland.

On behalf of Maternal Death Enquiry Ireland I propose to explain the background to this issue and outline the very good health care that is available to women in Ireland. Maternal Death Enquiry was established in the 1950s in the United Kingdom and has since then produced a number of good reports which have improved the care of patients in obstetrics. Ireland became involved on the basis of the scientific approach taken to ascertaining the causes of maternal deaths and because we could learn more by being part of a larger cohort of patients or, unfortunately, deaths of patients. In 2007, we established a working group to initiate a confidential inquiry with the support of the then Department of Health and Children, the HSE, the Institute of Obstetricians and Gynaecologists and other interested parties. The inquiry commenced in 2009.

I will now speak briefly on the definitions of maternal death. We refer to direct deaths as those resulting directly from pregnancy. Indirect deaths result from diseases which existed prior to or developed during pregnancy and were aggravated by the physiological effects of pregnancy. Coincidental deaths are those where the pregnancy was only coincidentally related. As it is difficult to identify the nominator when calculating maternal mortality rates, we take the figure used in the United Kingdom, namely, 100,000 maternities or those women who deliver babies alive or older than 24 weeks and stillborn.

The great value from undertaking this inquiry is that the case ascertainment in confidential inquiries internationally has been shown to detect somewhere of the order of 1.5 to two times the number of maternal deaths found in civil registration procedures. There are many reasons for this discrepancy. Confidential inquiries are also valuable because they can assess the causes of death and identify whether lessons should be learned in terms of altering care or improving outcomes for women during pregnancy.

We have carried out comparisons in Ireland with the CSO's figures. Maternal mortality in Ireland is often touted as being low compared to other countries. The triennial report for 2009-11 identified 25 maternal mortalities based on the scientific approach of the maternal death classification system. Of these mortalities, six were classified as direct maternal deaths or associated directly with pregnancy, 13 were indirect maternal deaths and the remaining six were attributed to coincidental causes. During this period there were 225,136 maternities in Ireland, giving an overall rate of 8.6 maternal deaths per 100,000. It is important to note from a care point of view that there was no evidence of clustering in any hospital. The exercise should be treated with caution given that it is the first time to attempt it in Ireland and perhaps some cases were not identified but we have received a phenomenal response from clinicians not only in maternity units, but also general hospitals. Our maternal mortality rates compare favourably to our nearest neighbours if we use the same classification system. During the period in which Ireland experienced 8.6 maternal deaths per 100,000 maternities, the UK experienced a rate of 11.3. If one takes international civil registrations of maternal deaths, Ireland again has a comparatively low rate of maternal deaths.

In regard to causes of maternal deaths, direct deaths are closely associated with pulmonary embolism, or clot to the lung, amniotic fluid embolism and multi-organ failures secondary to a condition called HELLP, which is associated with pregnancy. Indirect causes included cardiovascular disease, influenza including the H1N1 variant, epilepsy, chronic obstructive pulmonary disease and bleeding esophageal varicose veins.

There were also two suicides, one of which occurred during pregnancy and the other during the postpartum period after the woman had delivered her baby. Both cases were well known to the psychiatric services and under care. The notifications for 2012 have also identified three women who committed suicide around the time of pregnancy, one during pregnancy and two post-delivery, all of whom were known to the psychiatric services. This indicates that pregnant women in Ireland are availing of a very high level of health care. While these figures are inevitably a factor of Ireland being a wealthy country with a highly educated population and excellent health care system, it is important that women understand this country has very good results. We need to take away some of the scare concerns the public has.

The value of the confidential inquiry is that we have a really good baseline for one of the markers for maternity care in Ireland and it shows that we are doing exceptionally well. We do not have information on whether termination of pregnancy has reduced or otherwise affected these figures. Inevitably it is part of the total health care package that will continue to assist women in having, I hope, successful pregnancies.

I wish to make an initial statement and then pass to Professor McAuliffe.

Professor Harrison has ten minutes.

I will not take ten minutes.

The witnesses have ten minutes between them.

I am chairman of the Institute of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland. The institute is the corporate representative of obstetricians and gynaecologists in Ireland. Based on our standing orders, its objects are to represent obstetric and gynaecological opinion in Ireland in a professional advisory and administrative capacity; to act as the advisory body in Ireland in matters relating to education, training, research and administration in the specialty of obstetrics and gynaecology; and to promote excellence in the areas of patient care, professional standards, education and research in obstetrics and gynaecology. There are approximately 120 professionals in obstetrics and gynaecology in Ireland. That number has remained static, despite a 40% increase in the number of births. There are 126 trainees. The institute has 223 members or fellows, of whom 24 are associates in training. The executive council, on whose behalf this presentation is being made, has members elected from the body from various areas throughout the country, including Northern Ireland. The duration of my position on the executive council is three years. We are the group that really represents our specialty.

Our brief, as stated in the letter, is to make a presentation solely on the implementation of the recent Government decision following the publication of the expert group report. I am no longer involved in clinical practice, although I am still on the specialist register and, therefore, feel it more appropriate that our position be given by someone who is on the register, namely, Professor Fionnuala McAuliffe who, among other things, is consultant obstetrician-gynaecologist and specialist in maternal and foetal medicine at the National Maternity Hospital. She is also head of the faculty of women's and child's health at UCD. Present to help her with questions is Dr. Meabh Ní Bhuinneáin, consultant obstetrician-gynaecologist at Mayo General Hospital. I will try to keep quiet, unless my experience of 47 years is needed.

As we have heard from Professor Greene, maternal health services in Ireland are among the best in the world. Pregnant women and their families should be reassured that they are receiving the very best of care in pregnancy. One measure of maternal health services is maternal mortality rates, about which we have just heard. Our accurate figures in Ireland show that these rates are approximately one mother dying per 12,000 pregnancies. These low rates compare very well with those in the United Kingdom and the rest of Europe.

Another measure of maternity care is the number of cases of severe maternal illness during pregnancy. This is the number of women who, without timely treatment, risk maternal death. Ireland is one of the leading countries to collect this type of information. The rate of severe maternal illness during pregnancy recorded in Dublin is three per 1,000 pregnancies, which compares very favourably with the Scottish data of four to six per 1,000 pregnancies. However, we are never complacent and it is our absolute priority to ensure pregnant women receive the very best of care. In order to maintain these very high standards and improve on them, we need to continually adequately resource our maternity services.

I will make some general comments on the report of the expert group on the judgment in the A, B and C v. Ireland case. We very much welcome the opportunity to have an input and applaud the expert group report. It is important that obstetricians have legal clarity when making difficult decisions regarding termination of pregnancy or delivery of a very premature baby when treatment is required to ameliorate the threat to a mother's life. The situation where termination of pregnancy or delivery of a very premature baby is required in order to avert a substantial risk to the life of the mother is rare, although it does occur. The majority of cases we see as obstetricians arise in women with prior medical disorders such as severe heart, lung or liver disease, or where a mother develops severe pregnancy-related blood pressure. If the baby is delivered at a stage before it can survive, unfortunately, it will die. However, once the baby reaches a stage where it can survive, it is current practice that every effort be made to support its life. The test to be applied can only be a medical one, to which exact precision and timing cannot be applied. As doctors, we deal with probabilities and cannot precisely predict death or its timing. However, obstetricians are the experts in maternity care and if two senior obstetricians in consultation with the appropriate medical specialties consider there is a substantial risk to the life of the mother which can only be ameliorated by termination of pregnancy or delivery of a very premature baby, we will take this decision. That is our current clinical practice and it is imperative that we be allowed to continue this practice in the interests of pregnant women in Ireland. These are complex and difficult cases and a multidisciplinary team approach is required. However, obstetricians are those clinicians who are experienced in the care of pregnant women and, therefore, should be central in the assessment of sick pregnant women and to any decision-making process when there is a substantial risk to the life of the mother.

I will now make some specific comments on the report of the expert group. Chapter 6 deals with the procedures for determining entitlement and access to termination of pregnancy. On paragraph 6.2 outlining the test to be applied, as stated, it can only be a medical decision with appropriate documentation. On paragraph 6.3 dealing with the qualifications of doctors involved, it is the view of the institute that this should be a consultant obstetrician on the specialist register. On paragraph 6.4 dealing with the number and role of doctors involved, it is the institute's view that it should be two consultant specialist registered obstetricians and gynaecologists, plus, where the condition under review warrants this but only then, other consultants on their own specialist register as a team assessment. On paragraph 6.5 dealing with emergencies, it is the view of the institute that no special provisions are required and that established clinical practice guidelines for emergencies will apply.

In regard to paragraph 6.6 dealing with location, the considerations listed were acknowledged, but it was considered that all licensed general hospitals, not just recognised maternity units, should participate in providing these procedures, as necessary. Mothers with complex medical disorders are often cared for in general hospitals with access to intensive care. Therefore, it is imperative that all recognised licensed hospitals be able to provide these life-saving procedures.

Where neonatal care is not available to care for a very premature baby, and provided the woman's health allows, in utero transfer pre-delivery to a unit that has appropriate facilities should be considered. This is established current practice in Ireland.

With regard to the formal review process under paragraph 6.7, it is the institute's view that the medical model at the woman's request or by another person acting on her behalf is the preferred option. With regard to the composition of the review panel under paragraph 6.7, it is the institute's view that all specialties are to source and provide from within their appropriately qualified ranks consultants practising in Ireland to form a panel that can be called upon for a second opinion. There should be a minimum of two obstetrician gynaecologists plus other specialties similarly qualified, as appropriate. In obstetrics and gynaecology, the institute would act as a list provider. The panel should be indemnified against possible subsequent legal proceedings and have access to formal legal expertise. With regard to the convenor under paragraph 6.7, it is the institute's view that a nominated person or unit in the Department of Health, whom the woman can access directly, should convene the panel from the list supplied by the professional bodies. With regard to access to courts for appeal and conscientious objection under paragraphs 6.8 and 6.9, these were acknowledged as read and, in the latter case, it was noted that this may extend to other health professionals. With regard to the monitoring system or monitoring review panel under paragraph 6.10, it was the view that these important cases need close monitoring and regular review. With regard to chapter 7, options for implementation, it is the view of the institute that statutory legal protection is required for health care professionals and patients. With regard to alternatives for implementation under paragraph 7.4, it is the view that paragraph 7.4.3, concerning legislation plus regulation, provides the necessary flexibility and protection for health care professionals and their patients.

In conclusion, we are grateful to have the opportunity to participate in the discussion. We respectfully request that the institute have input into the final wording to ensure we are allowed to continue with current practice, which includes the provision of life-saving treatments to pregnant women.

I have two questions, the first of which is to Mr. Niall Behan of the Irish Family Planning Association. With regard to the submission made about the services the IFPA provides in assisting people in the decision they make, we know this is a very complex area and that circumstances can arise in which a woman decides that, ultimately, a termination is most appropriate for herself. Listening earlier to the psychiatrists and their analysis and interpretation of statistics and facts, I saw clearly that there was even some divergence among those eminent people. Does the IFPA assist people in terms of accessing psychiatric services first and foremost, or does it consider that if a person has made a decision to terminate a pregnancy, for mental health reasons or due to suicide ideation, intent or otherwise, it should suggest that maybe, initially, some form of psychiatric support is the most appropriate option? The evidence to date from the psychiatrists suggests that intervention is of assistance and it is not necessarily the case that termination is the correct decision at the end of the day. If a woman is given assistance, she may ultimately decide that a termination is the only option for her, but at least she would be given support.

On the issue of lack of legal clarity, have the representatives of the Institute of Obstetricians and Gynaecologists, in their professional capacity, ever had difficulty in arriving at a decision to intervene and interrupt a pregnancy to save the life of the mother? We hear a lot about the fact that this is seldom carried out as a procedure to save the life of the mother and there are varying views as to how many such interruptions are carried out every year - we have heard mention of 20 to 40 times a year. Have the representatives of the Institute of Obstetricians and Gynaecologists experienced circumstances in which they felt they could not intervene at a particular stage to save the life of the mother because of lack of legal clarity or the threat represented by sections 58 and 59 of the 1861 Act? Has that affected their professional capacity to intervene in saving the life of the mother?

I join with other members in welcoming all of the panellists. To address Mr. Behan's contribution on behalf of the Irish Family Planning Association, I note that in his submission Mr. Behan has very correctly pointed out - this is also my opinion, and a number of colleagues have already expressed a concern in this regard - that the first point of contact is often with the local GP, although, sadly, GPs do not have an opportunity to come before the committee over these three days. Mr. Behan said: "The experience of the IFPA and of many doctors is that medical service providers in Ireland are prevented from acting in the best interests of pregnant women's health, and must navigate the grey areas of the law". That is an important point to make.

When Mr. Behan went on to talk about those who avail of the IFPA's services, he noted the fact that there are a small number of people presenting for whom the risk to their lives is real and identifiable. Of those who do, he indicated that a very small number again, which is consistent with all of the evidence we have had, have suicidal ideation or intent. Can Mr. Behan give us any indication of the numbers of those who might have attempted suicide over the period of time? I am hoping "unsuccessfully" would be the point to add. Does Mr. Behan consider it likely that women who have the financial means and who have either suicidal ideation or suicidal intent will continue to travel in order to access abortion services rather than face the psychiatric services within this State? Is that something he would recognise?

Professor Greene's presentation with regard to maternal death enquiry, MDE, was broadly statistical, I think it is fair to say. I welcome the statistics he has shared with us. He has not drawn any conclusions per se in terms of his contribution, either in writing or orally, today. Would he like to elaborate on this in any way, particularly in regard to table 2 and the comparisons with other international settings? Are there conclusions of views that he would deduce from the information presented in table 2?

Time beats us all the time here. None the less, in conclusion, I welcome the obstetricians and gynaecologists and I thank Professor McAuliffe for her contribution. I seek one small clarification. She made the point that in certain circumstances general hospital settings could be appropriate for particular decisions to be taken, which is outside the remit of obstetricians and gynaecologists. However, many of these general hospitals do not have maternity units. Will Professor McAuliffe elaborate on that and give us a sense of the situations she would see as appropriate to the particular point she shared with us in the course of her contribution?

I thank all contributors for their evidence thus far. I would like to ask the Institute of Obstetricians and Gynaecologists how it deals with minors - young girls who present as pregnant to its services. We had some discussion about this earlier with the psychiatrists and I would like to obtain clarification for the committee. Is it the case that medical consent can be given by somebody at the age of 16, with the anomaly this throws up in terms of persons being recognised in law as children up to the age of 18? What is the institute's procedure for making an appropriate referral for that child? We heard from Professor O'Keane in the last contribution that pregnant teenagers are at a much greater risk of dying by suicide than non-pregnant teenagers. I would like to get the witnesses' real-life experience in regard to how they deal with young people - children and adolescents - when they present in their clinics.

Among the recorded maternal deaths, were any of the women who tragically died under the age of 18?

How will the review panel with a convenor, mentioned by the obstetricians and gynaecologists, work in practice? I have a vision of a young woman in crisis being told to put the crisis aside for a couple of hours or days or weeks. What will this look like in respect of getting a second opinion from the review panel by contacting the convenor? How will that work for practitioners and people receiving the service? As Niall Behan correctly pointed out, the European Court of Human Rights recommended that whatever we do must be tangible and practical. It cannot be theoretical and cumbersome particularly for women who find themselves in crisis.

I have a series of short questions for Professor Greene, for the benefit of my colleagues who do not have a background in interpretation of medical and epidemiological statistics. Will he elucidate the difficulties which occur in attempting to draw conclusions statistically when one is dealing with such small numbers? Several statements have appeared in the lay media suggesting that one could define a cause and effect relationship between the availability or non-availability of abortion services in a country and its maternal mortality rates. I would be troubled by that supposition because maternal mortality is such an extraordinarily rare event that it is very hard to make any kind of calls and statements with regard to other potentially confounding factors. It has been frequently suggested that not only is this one of the safest countries in the world from the point of view of maternal mortality but that it is number one. It has been suggested that this is somehow because we do not have legalised abortion.

Could my colleagues from the institute answer a question I have asked repeatedly of professional representatives today - are they aware of any case in the history of this State where a woman died needlessly as a result of the legal vacuum surrounding abortion? I am not trying to stray into individual cases or to ask for editorialisation about contemporary cases. Has it happened in the past 30 years, since the issue came onto the constitutional horizon? Will the institute be recommending that there be a specific and relatively liberal regime for making emergency decisions with respect to the need for abortion when the mother's life is in danger?

The role of the Irish Family Planning Association in giving post-abortion counselling has become an issue-----

The Senator should deal with the specific topic for today rather than straying into that area.

I will try not to stray into other areas but the association does provide post-abortion counselling services. Will the witnesses clarify how in the event of a legal change it would police the medical veracity of what is said to clients attending their clinics?

In response to Deputy Kelleher's question about the lack of legal clarity, we feel strongly that it is in a patient's and the public interest that doctors work within a legal framework. If a woman is at substantial risk of dying in the immediate hours and days, there is no legal difficulty, we press on and offer treatment. I am, however, aware of cases in which there is a substantial risk to the woman's life which is not immediate and around which there is legal uncertainty. We have referred those cases to the UK for treatment.

In response to Deputy Ó Caoláin's question about general hospitals and termination of pregnancy, most of the cases we deal with involve patients with severe medical disorders. Many of them need access to intensive care units, physicians and so on, for example, a patient with a deteriorating heart problem would be in coronary care in a general hospital. If a time came when we felt that termination of pregnancy or delivery of a very premature infant was required that would happen in the general hospital because the maternity unit would not have the facilities to look after that patient. That is why we feel strongly that the general hospitals need to be included. If, for instance, the woman was in an intensive care unit in a general hospital and deteriorated suddenly and needed delivery of the baby there would not be time to transfer her to a maternity unit. It would not be safe to do so. That is why we feel these life saving procedures should be carried out in all hospitals. Most of our patients are medical patients and need access to intensive care units and physician input. Many of these are already being cared for in general hospitals.

In response to Deputy Conway's question about minors, the age of consent is 16 so if the patient is over 16 we treat her as any other patient. If she is under 16 her next-of-kin needs to consent. Thankfully, our rates of teenage pregnancy are relatively low. If the patient was medically very unwell and was under the age of 16 we would require her next-of-kin to consent on her behalf. If she is very unwell we will go ahead and treat her. If somebody was at substantial risk of a life-threatening problem she would receive intensive psychiatric or medical treatment. That treatment would continue and the issue of delivering the baby earlier, termination of pregnancy, would require her input and that of her next-of-kin.

In regard to the review panel, the patients we are discussing are usually receiving intensive medical treatment which is ongoing and the issue of the termination of pregnancy or delivering the baby early is part of that package but the other treatment will continue in the background. I agree with Deputy Conway that we need a review panel that would be timely. We discussed this at institute level and decided that there should be a panel available of ten, 20 or 30 doctors so that one could quickly get a second opinion if required. The details will have to be worked out but I totally agree with the Deputy that we need something that will act in a timely way and will be workable. The psychiatrists have a system for a second opinion in place whose structure we might consider for this panel.

In response to Senator Crown I am not aware of any case in which a woman died as a result of the legal vacuum. If a woman is in imminent danger we press on and treat her. One of our concerns about the emergency situation is that if a woman is really very unwell we do not want doctors to delay treating her because they have to get two consultant obstetricians, plus or minus a physician, filling out paperwork while she needs to proceed to deliver the baby either before or after viability. I am not suggesting any great change in practice. If any pregnant woman in any hospital in the country is very unwell she will receive treatment. It is important that doctors be protected so that in the emergency situation they can get on and deliver that emergency treatment.

In response to Deputy Ó Caoláin's comment about the absence of a conclusion, I was giving a factual account, the most recent and detailed account of maternal mortality in Ireland. The only conclusion I can draw is that when we do that we have figures that are very good in comparison with the rest of the western world. It is a marker of the health care provided to women in Ireland. In another conclusion and in partial response to one of Senator Crown's questions, I do not have evidence to support in any way the claim that we are number one or are in the top few with respect to maternal mortality because we do not have termination. That evidence would not stand up internationally when one reads literature on maternal mortality. In fact, many developing countries provide termination and their maternal mortality rates are in the order of between 800 and 1,000 per 100,000.

Countries in Europe which have social and medical termination of pregnancy have the same region of maternal mortality as ourselves, so I do not think such conclusions can be made. What we are looking at is the fortune of an educated, well-fed healthy population with good medical health care which includes a component, as Professor McAuliffe noted, of undertaking the termination of pregnancies appropriately to protect the mother's life.

In response to Deputy Conway's question on women under 18, the answer is "No", thankfully. To answer questions on clarifying the statistics, in table 2 we give the figure of 8.6 per 100,000 and we show a confidence interval thereafter. If this figure is taken on average and worked out statistically we would see no difference between 5, 4.7 and 12.4; we could be anywhere in this group of figures and be the same, so effectively what these statistics show is that we are not dissimilar from the UK.

I will answer Deputy Kelleher's question on the issue of women who might present with suicidal ideation. In the first instance if they were already attending a psychiatric service they would be encouraged immediately and facilitated to liaise with that psychiatric service before making any full decision. If somebody presented who was not in contact with any service we would seek, if possible, to liaise with her GP to try to arrange for her to have appropriate care before she would make a decision. In the event where somebody is absolutely certain, has already come to a decision and does not wish to do any of these things, it is an individual case of trying to add up what is in that person's best interest. Overall our idea is to try to liaise with psychiatric or general practice services to assess a woman and help her with her mental illness.

To answer Deputy Ó Caoláin on whether women might still choose to travel, this will be an individual choice and some women would still choose to travel even if they felt they might meet the criteria because they might not want to have the delay or the problem of going through the assessment. Other women in that position who cannot afford to travel would certainly be very much able to be facilitated by the service.

In response to Deputy Ó Caoláin with regard to our two clients who attempted suicide, thankfully they were unsuccessful in their attempts. These two cases happened within the past three years and that is as far back as we looked. One of the clients specifically mentioned a particular barrier to being able to travel to the UK for an abortion as one of the reasons she attempted suicide.

With regard to accessing psychiatric services, abortion services and mental health services are still very much stigmatised in Ireland and many of our clients express strong views on this. They speak about the personal and social implications of accessing abortion services and psychiatric services. It is our experience that women who are not involved in psychiatric services who want to travel for a termination to the UK will travel in preference to being stigmatised, as they would see it, with a mental health illness.

With regard to Senator Crown's question, the IFPA has in place a range of stringent policies and procedures for our services and if a specific complaint is made to us which is apparent and viable we can deal with it. We have been in contested areas of public discourse and have provided services for the past 40 years so it has always been like this for our organisation and we must have these policies and procedures in place.

A number of speakers are offering and I ask members to be brief.

I have a question for the Institute of Obstetricians and Gynaecologists on the options set out in the expert group report. I asked this question this morning and I seek clarification. Three options are given with regard to the decisions to be made by psychiatrists. These are: that the decision would be made by two psychiatrists or two specialists; that the decision would be made by a psychiatrist or specialist and an obstetrician; or that the decision would be made by two psychiatrists or specialists and an obstetrician. What is the view of the institute on cases where the issue of suicide is raised? Should an obstetrician be part of the decision-making process?

In smaller units from 5 p.m. on a Friday to 9 a.m. on a Monday only one obstetrician is on call. What procedures are in place at present to give support where a decision must be made by an obstetrician? What procedures would the institute like to have in place? In many smaller units a locum is brought in during holiday periods and works at weekends. What supports does the institute suggest putting in place to deal with an emergency or a situation where decisions must be taken to terminate a pregnancy?

I thank the witnesses for their presentations. We are here today as part of the legislative process and we will spend three days listening to medical and legal professionals and other groups putting across their viewpoints on a very complex issue. The wording of the legislation will be very important and I hope when we come to it that the wording will be correct and that the medical profession will have legal support when a decision to terminate a pregnancy must be made in the very rare circumstances it will arise. We must trust our doctors and medical professionals. We have heard from the masters of the big maternity hospitals in Dublin. We also have wonderful maternity hospitals throughout the country, in particular in the west of Ireland and I welcome Dr. Meabh Ní Bhuinneáin from Mayo General Hospital. I had a rare disease and I am very lucky to be alive. I do not think of Dr. Ní Bhuinneáin every day but I do so from time to time and I am very glad she stayed in the west of Ireland and is so involved in her profession. I do not have a question but I am disappointed we do not have somebody from the GP association before the committee, because sometimes a pregnant woman goes to her GP because she is troubled but will not go any further.

That is right.

In Sligo, GPs have referred people to the Marie Stopes clinic in Belfast and I am disappointed we do not have anybody from the IMO before the committee.

It was invited but declined.

I welcome our guests and thank them for coming and giving their views. In particular I thank the medical professionals. I am also disappointed the IMO has not come before the committee but at least it was invited. Others were not invited and are not happy. The IFPA website states it believes abortion is an aspect of private life and has to do with reproductive rights. It also states it supports the choice of access to termination during pregnancy in all circumstances. This makes the IFPA, which is partially taxpayer funded, an abortion advocacy group. Considering this, does it support choice in all circumstances? Does it think the unborn child is entitled to any protection under the law? I also query the consultation the other groups had with their members.

People have complained that they were not consulted, which would be unfortunate if true. South Tipperary General Hospital has top class facilities. All of my children were born there. I thank the hospital for the excellent delivery service provided by its midwives and doctors.

It would be unfair to say that the Irish Family Planning Association, IFPA, was an advocate of abortion. It is a sexual health and reproductive rights organisation.

Let it answer the question.

The IFPA provides information and support to 5,000 women and girls experiencing pregnancies. How many had suicidal thoughts and how many committed suicide? What approach did the IFPA take to those women and girls? It has stated that women and girls in Ireland who require abortion services experience stigma and discrimination and lack support and information from the State. Will the delegates elaborate in this regard, please?

I will take all speakers together.

A number of my questions have already been asked. When Dr. Ní Bhuinneáin responds, will she address the comments of Senator Colm Burke? They are relevant in the west.

Mr. Behan stated that the IFPA catered for 5,000 women annually and that it had encountered two cases of attempted suicide in a three-year period. When Professor Veronica O'Keane presented earlier today, she made the point that the level of threatened suicide and suicidal intent and ideation encountered by front-line services was far higher than was encountered by perinatal consultants, as the former met many of the clients in question. The IFPA sees many women and the figures it has provided seem to tie in with those of the perinatal consultants, not those provided by Professor O'Keane. Will the witnesses clarify this point?

To clarify, is it Professor McAuliffe's opinion that no special provision should be made for emergencies? I presume this was only meant in the context of the expert group report and that she is actually seeking special provision for emergencies and that the current procedures would be maintained, would not fall under the terms of new legislation and would not require a second consultant for approval. Will she clarify whether this is the case?

My final question is for Professor McAuliffe and Dr. Ní Bhuinneáin. There are 120 obstetrics and gynaecological consultants. Are the witnesses satisfied that there is an adequate geographic spread of those consultants to ensure that existing maternity facilities can provide the services in question and make decisions in the difficult situations that may arise?

Most of my questions have been asked, but I will ask one of the Institute of Obstetricians and Gynaecologists. We are dealing with this issue on the basis of the probability of a real and substantial risk to the life of the mother. What is the institute's opinion in terms of fatal foetal abnormalities? Does this issue fall within the context of a real and substantial risk to the life of the mother and, if so, how?

Professor McAuliffe mentioned referring some women to England. What were the reasons, how many has she referred and did she make those decisions because of the inadequacy of current legislation?

My question will follow on from Deputy Dowds's. Professor McAuliffe mentioned that, when the substantial threat or risk to the life of the mother was immediate, professionals knew exactly what to do, but that there was a grey area when the threat was not immediate. Professor McAuliffe stated that, in certain scenarios, she sent the latter category of women to another jurisdiction to be treated before returning to her. If she wanted to include this category in legislation, how would she suggest it should be framed?

I seek a point of information. I am glad to hear that Ireland is probably one of the safest places to have a baby. Why did the IFPA enclose in its submission legislation from a number of European countries? Was it purely for informational purposes or did the IFPA have a specific reason for doing so?

We only have 29 minutes remaining in this session. Professor McAuliffe might commence.

I wish to clarify for Senator Colm Burke the point about two obstetricians. Having discussed the matter in detail, we believe that two obstetricians would be involved in making decisions in all cases where it was felt that the termination of a pregnancy or the premature delivery of a baby was required. Whether the threat owes to suicide, heart disease or lung disease, obstetricians should be central. Two obstetricians plus the relevant specialist registered psychiatrist should be involved.

Deputy Mattie McGrath referred to the consultation process. We convened a group of senior institute members on 4 December, discussed the report in detail, devised a draft document, circulated it to the members of the institute's executive and discussed it on 14 December. The executive's members are chosen from and represent their regions. Their role is to communicate with their members within each region. The document was passed unanimously by the executive on 14 December. There was adequate consultation with the institute's members.

Deputy Naughten mentioned emergencies. In emergency medical situations, the usual procedures and policies are often put aside to prioritise the provision of medical treatment. The same would pertain were a woman's life in serious danger. If she needs immediate treatment, one obstetrician should be sufficient. We would not expect the requirement for two obstetricians or the usual paperwork to pertain, as women's lives could be lost. In emergency cases, people often write their notes afterwards. The priority is to deliver first-line medical services.

Regarding the question on fatal foetal anomalies, the institute's remit was to give an opinion on the expert group report, which was confined to a substantial threat to the life of the mother. It was not within our remit to address fatal foetal abnormalities. Our brief is confined to the report.

Deputy Dowds asked about the legal framework. There should be a legal framework in which we can act in these cases. We do not have a register of the cases in question. As a maternal medicine consultant, I am a specialist in this area and I see many such cases. There are a number of cases every year in which there is some legal uncertainty. We refer those patients abroad for treatment. I do not have the exact numbers. It is important for our patients and the public that doctors work within an appropriate legal framework. We request that legislators provide a robust framework.

I was asked about how we deal with cases of immediate risk and so on within the legislation. Medical expertise plays a role in this regard. We have experience of looking after pregnant women and we have knowledge of the literature. If two senior obstetricians believe that there is a substantial risk to the life of the mother - we will not define percentages or timelines, as doing so is impossible - the criteria will be fulfilled. Legislation to this effect would cover all situations in which there is a substantial risk to the life of the mother.

I am happy to answer the questions on the smaller units. I thank members for their favourable comments on the maternity service in the west at this time.

On the smaller units, which issue was dealt with at length this morning with Dr. McCaffrey, these services are in isolated areas and operate out of hours. Unfortunately, obstetrics tends to be busier out of hours than during normal working hours. There has been much change in this area over the past ten years as a result of the review of maternity services. There are now informal networks linking hospitals all around the country with the maternity units in each area. These networks are not formalised in every part of the country but they do afford a greater communication between tertiary specialists. Also, owing to mobile phones, the ability to contact colleagues out of hours is greater.

In terms of a consultant going off duty in a small unit leaving the duty of care with a locum, the substantive consultant has a duty to ensure that the locum is suitably qualified for the services. We have experienced huge difficulties staffing these units. However, for the purpose of today's discussion, if the substantive consultant is not adequately satisfied that the locum can perform all duties that might arise, he or she would not then be able to go fully off call. While the response time might not be the ten to 15 minutes for obstetrics which is often the case, the consultant will be responsive by phone and be able to return to the unit within 30 or 60 minutes, which in the type of situation we are discussing today is often the timeframe involved.

There is recognised urban drift of professionals and different working groups towards the urban centres, which is difficult in a country that does not focus on rural training and streaming in the context of the delivery of these services in the long term. In practice, it is possible in many situations of imminent risk to get second opinions and often to get a second pair of hands. It must be remembered that currently all the maternity units are sited in general hospitals outside the free-standing maternity units in Dublin so that there are specialties who have not been involved in this process, including general surgeons who attend emergencies and general physicians and anaesthetists with intensive care expertise who are part of teams on duty at weekends. The brief needs to be widened to include other medical practitioners who will of course be governed under the Medical Council provisions that will change in due course as the Government legislates on this issue.

The question was asked as to whether we are satisfied that with a consultant spread of 120 we have enough geographical spread. That will depend on what happens with reconfiguration. The reason we have sought regulation with the legislation is to ensure we can adapt to situations as they arise. If a unit suddenly loses some aspect of its acute service then the geographical spread might not be acceptable. We may have to regulate for this to adapt as time proceeds.

I will respond first to Deputy McGrath's question on the IFPA. We are a medical organisation and see 20,000 clients per annum. We have reached our conclusion on abortion and criminalisation of abortion based on our dealings with the many women who have come to our services. As a result of that dialogue, we believe it is best that these decisions are left to the woman and her doctor and that criminal law should not come into it and does not serve any purpose in this discussion.

The fear is that if criminal law is removed the abortion rates will increase. We know that this is not true. There is enough evidence available which suggests that the criminal law does not impact on abortion rates. That is the reason we included some information in our submission on what happens in other countries. We also included that information because in the A, B and C judgment the court suggested to the Irish Government that in seeking to resolve these very difficult issues, it should look to what happens in other European countries. As such, we need to look beyond the UK, which is to where we usually look for an answer. That is the reason we included that information in the submission.

Other questions - I apologise if I have not taken on board everybody's questions - were on issues such as suicidal thoughts and how many clients we saw. I referred in my opening statement to two female clients who had followed through on their threats and committed suicide. Many more of the women we saw may not have been suicidal but owing to mental health reasons such as depression and so on were in crisis pregnancy. The vast majority of those women have travelled to the UK.

On the criminalisation of abortion, how we might respond to that and our view in regard to the unborn, we must look to what has happened around abortion rates in Ireland during the past ten years, which rate has decreased fairly substantially. The last time there was a similar hearing to this on the abortion issue, parliamentarians heard from a range of people. The medical advice given to parliamentarians at that time was that to reduce abortion rates we needed better sex education and greater access to contraception. From that the Crisis Pregnancy Agency was established. That has been successful in terms of reducing abortion rates during the past ten years.

Would Professor Greene like to comment?

No.

There are 15 minutes remaining for this session. I call Deputy Ó Caoláin.

I had only limited time to question the obstetricians and gynaecologists and would like if I may to put some further questions on that issue to Professor McAuliffe. On the 1861 Act, I expect that it would be the professional experience of Professor McAuliffe and her colleagues that there are no instances in their knowledge where the overhanging threat of that extant legislation would have impacted negatively on decision making by professionals. However, as others have already indicated to the hearing during earlier sessions, there is a great discomfort at the fact that this legislation remains on the Statute Book and all that this implies in terms of contravention of the law as it stands and the possibility or risk of legal action being taken against a practitioner. I would welcome if Professor McAuliffe could elaborate on that point and presume she will confirm that while there are no known cases in that regard, there is nevertheless a powerful discomfort that needs to be addressed by the removal of that legislation.

I would also like to raise at this point one final question which has not been asked in the course of questions to the witnesses before us. Uniquely among the contributions made here today in relation to the composition of the review panel, the Institute of Obstetricians and Gynaecologists indicated it would accept appointment of a member of the legal profession as chairperson of the review panel, which merits a little elaboration as it is not something we heard in earlier contributions. I would like to hear further on that, please.

I have some questions for Professor McAuliffe in relation to the smaller units. The master of the Rotunda, Dr. Sam Coulter Smith, made the point earlier that there is a need to put in place a referral pathway for decision making in the case of smaller maternity hospitals.

Dr. Ní Bhuinneáin made the point that in the situation prior to reconfiguration there would be another specialist in the hospital, perhaps not another obstetrician but another specialist. I presume her recommendation is the second option, that the sign-off would be made by an obstetrician with one other specialist. Is that her view or does she believe there should be this pathway, as was referred to earlier this morning?

On the issue of suicide, Dr. Mary McCaffrey made the point that none of her colleagues for whom she spoke this morning had felt they were competent to deal with making a decision on termination on the grounds of suicidal intent. In these circumstances does Dr. Ní Bhuinneáin believe it should be up to the perinatal psychiatrist to make the call in that regard or should the obstetricians have a direct role in making the decision?

In response to Deputy Ó Caoláin, we feel strongly that there must be a legal framework within which to make our clinical decisions. That would protect the public, our patients and health care professionals. We are not aware of a case of maternal death because obstetricians were reluctant to act, but we strongly feel robust legislation is needed to give a framework for our work.

In respect of the chair of the review panel, we discussed this issue briefly and felt they could be recruited from either the medical or the legal profession. That is our position; we have not come down strongly on one side or the other.

In response to Deputy Naughten regarding the situation in smaller hospitals, if a woman presents at a smaller unit on a Saturday night with severe blood pressure and needs delivery as her life is in danger, that patient will be looked after. That must be clearly stated. We have lovely data from Professor Greene. Our units in the hospitals are of very high quality and the results are excellent. In an emergency a specialist can make these decisions and offer life-saving treatment. If time allows and the patient is unwell but not immediately in danger, one could refer her to a larger unit where, perhaps, there is more expertise available. However, if a woman arrives at any maternity unit in the country at the weekend, at night and is very unwell and needs delivery at whatever stage of the pregnancy, she will receive that treatment. That is part and parcel of running a maternity unit, regardless of its size. As Dr. Ní Bhuinneain said, if a patient arrives and there is some uncertainty as to whether she needs delivery, a second opinion can be sought by telephone. That is why it is important that we make provision for emergency cases, whereby one doctor can make this decision to allow a woman's life to be saved.

With regard to suicide, the institute believes two obstetricians should be involved in any decision to deliver a baby before or after viability, termination of pregnancy or delivery of a pre-term baby in the suicide case. We feel that in any case in which there is a substantial risk to the life of the mother, be it suicide or medical, two obstetricians should be involved in that decision.

I wish to comment, as a practising obstetrician, in response to Deputy Ó Caoláin who asked about the 1861 Act. I am not aware of cases, but, as a practising obstetrician, I am very aware of the difficulty that this causes for us on a regular basis. It is not uncommon for people working in the unit to have concerns, for example, about the constitutional equal right to life of the child. This comes up as a discussion point when one is making these very difficult decisions, which is why we need legal clarity on the issue. The other point is that it is very easy to make a decision if a mother is going to die because of excess bleeding or blood pressure to deliver her baby immediately. It is not very easy to do so where there is a threat to the life, but it could be some weeks or months down the road.

To clarify, Professor McAuliffe said two obstetricians should decide in the case of suicide. Is that correct?

Yes.

Does she mean two obstetricians and one psychiatrist?

Yes.

The expert group report gives three options which does not include that one. Is the institute going outside the expert group report's recommendation?

Yes, we are. We feel there should be two obstetricians who are on the specialist register making any decision if there is a substantial risk to the life of the mother, plus any number of other specialties required. If it is a psychiatric case, we might need one or two psychiatrists. If it is a liver case, we might need a liver specialist and if it is a heart case, we might need a cardiologist and a cardiac surgeon. In any situation where there is a substantial risk to the life of the mother where termination of pregnancy or delivery of a very premature infant is required, we strongly feel two obstetricians on the specialist register should be involved in that decision.

We will proceed to the session of 20 minutes duration for non-members of the committee. I call Senator Walsh. I apologise for omitting to call him in the last session.

Thank you, Chairman. As we come to the end of the first day of hearings, we can be reassured about the very great degree of confidence in the quality of our maternal health care. In fact, Professor Greene started by talking about women availing of the very high level of health care on offer in this country. I welcome the statement of the obstetricians and gynaecologists that outcomes and maternal health care here compare favourably with best international comparators.

I have a question for the obstetricians about the duty of care. Do they think the current two patient model is one we should try to preserve and that there should be a duty of care to the baby in any legislation introduced? Second, with regard to legislation, a number of the groups have made the point that they are anxious that the 1861 Act be repealed. If it is repealed, should there be sanctions in certain circumstances for illegal abortions?

Will the IFPA representatives identify circumstances which occur in the other countries they mentioned where they would disallow abortion or would they allow it in all circumstances? Do they consider that the unborn child is entitled to protection within the system and the legislative framework? I believe I understood Mr. Behan correctly when he said doctors were prevented from giving women the best care. That flies in the face of everything we have heard this evening and previously. Would he like to reconsider this in the context of these comments or will he give us evidence based, not opinion based, reasons if he does not resile from that position?

Dr. Sam Coulter Smith, an eminent obstetrician who appeared before the committee earlier, said such practices could put women's lives at risk. He was referring to the investigation currently under way with regard to Mr. Behan's association. Would he like to take the opportunity to clarify the matter and make an appropriate statement on it?

The Senator's question is out of order and I will not allow it. It would be unfair to the witness and the committee.

It is not. It is very pertinent.

The committee has discussed that issue. We are awaiting an investigation. The Senator is being unfair.

Will Professor Harrison say if the institute has consulted its full membership about the expert group report? What form of consultation was taken in that process?

My next question is for Mr. Behan of the Irish Family Planning Association. Considering the low level of maternal deaths in this country, why does he think Ireland is an unsafe place for a woman to be pregnant?

My questions are for Mr. Behan. Will he confirm his organisation's policy position as outlined on its website, which indicates that the association is in favour of - we will not upset anybody by using the word "advocate" - the availability of abortion in all circumstances?

That question is not relevant to what we are discussing in the context of the Government decision.

With respect, it is very relevant if an organisation is presenting here and if the stated policy of that organisation on its public website is that it favours the availability of abortion in all circumstances. I would like that to be confirmed.

My second question for Mr. Behan is that point 24 in his presentation mentions the need for progress and legislation before the next tragic case. We have heard today from a wide variety of witnesses who have all put on record that to the best of their knowledge, there have been no maternal deaths arising from our current constitutional position and legislation. Could Mr. Behan let me know what tragic cases he is referring to? Would he confirm his organisation is in full compliance with and fully respects the law of the land at present?

I thank the witnesses for their forthright and helpful information. Can we get some more specifics about the cases that Professor McAuliffe had to refer to Britain as a result of the lack of legal clarity in the Republic of Ireland? What are the circumstances surrounding them? This could be helpful when we are framing the legislation because information could help us to narrow down and define the problem we must address.

In helping us frame legislation, would the witnesses propose that time, support and intervention would be useful to a pregnant woman who believes she is at risk of suicide before a termination is provided? Would that be helpful? I am aware a lot of time is spent running around to get various things signed off before a termination but we should also think of the mother who is feeling suicidal and who believes she is suicidal. Bearing in mind all of the psychiatric evidence that abortion is not the way to treat to suicide, and given the job we must do to frame the legislation, what type of time, support and intervention would be helpful?

I thank the witnesses for their evidence. In the context of the institute's support for legislation and clarity, are we talking about transposing the current Medical Council guidelines so they have statutory standing and, if so, what is the institute's outlook on those guidelines as they relate to suicide as a grounds for termination?

How long has it been the institute's policy that we require a legal framework for this? As a public representative for some years, I do not recall having been lobbied by the institute previously to provide legislation in this area. Has the institute adopted this position recently on foot of the A, B and C v. Ireland judgment and the X case report?

In respect of the reference made about treatment abroad, are we talking about termination exclusively or the range of obstetric and gynaecological conditions, including human assisted reproduction, for which we do not have a legal framework here?

I am conscious a number of these questions are not directly relevant to the report of the expert group but I will answer as best I can.

On the issues around the circumstances in which protection would be given to the unborn, in part of our submission, we included information on what happens in other European countries. In other countries, some protection is afforded to the unborn at particular gestation periods and in particular circumstances. The difficulty in Ireland, and the expert group deals with this well, is that the constitutional referendum in 1983 tried to equate the life of the unborn with the life of the woman. Essentially that has given the unborn more rights than the woman in practice and we have women travelling to another jurisdiction for abortion services as a result.

On the remarks in our opening submission and women not getting the best care, we would not be here without the A, B and C v. Ireland case. We would not be here if that woman could have got a determination from her doctors. We would not be here today if C in the A, B and C v. Ireland case had got a determination and if the law was in place. Professor McAuliffe has already mentioned cases where women have had to be sent to Britain. From our perspective, the question is what would happen in those cases if a woman could not travel because she could not afford it or did not have the necessary documents.

The Irish Family Planning Association has always respected the laws of the State. That does not stop us advocating for our clients and bringing to the attention of lawmakers circumstances where the law is a barrier to health care.

I hope I have answered all the questions but I am happy to answer any more.

I asked a simple question. Is Mr. Behan's organisation fully compliant with current Irish law?

He has already answered that.

Yes, of course it is.

To answer Senator Walsh, as obstetricians we have an equal duty of care to mothers and their babies and that, of course, will always continue. While we would bow to the superior knowledge of our legal colleagues, it is our preference to have the 1861 Act repealed.

In response to Senator Healy Eames, at the moment, there is no legal certainty for us taking decisions where there is a substantial risk to the life of the mother. We have no legal framework for such decisions and that leads to uncertainty. To reiterate, these are rare cases, and I am aware of a small number where there is legal uncertainty. We have referred cases to Britain for a second opinion and the woman has had a termination in Britain and come back for continuation of treatment in Ireland. If we had legal certainty in these very rare cases where there is substantial risk to the life of the mother, where women have severe medical disorders, we could look after all women where there is a substantial risk. How could this be accommodated in the legislation? If senior doctors could act when they feel there is a substantial risk or threat to the life of the mother which can only be averted by termination of pregnancy or early pre-term delivery of the baby, that would cover the cases we come across where we feel uncertainty.

Is legislation or regulation required? We seek a legal framework and certainty and would defer to our legal colleagues on how that is best framed. At present there is legal uncertainty and we are looking for legal certainty, the nuts and bolts of which we would leave to the legal experts.

I will respond to the query about the expert group. This is the second time I have been asked this question. The answer remains the same. We convened a group of people from the institute on 4 December and came up with our report, which was circulated to the members of the executive of the institute. It was passed unanimously at the meeting of the executive which took place on 14 December. Each executive is represented because it represents an area within Ireland. It amalgamates the views of its members.

I was also asked whether we have been lobbying for this previously. The answer to that question is "No". Our remit was to respond to the expert group. The committee has heard that response today.

Would Dr. Ní Bhuinneáin or Professor Greene like to comment at this point?

I cannot remember who asked about the care given to somebody who has suicidal ideation in advance of the carrying out of a termination. Regardless of suicidal ideation or medical conditions, it is absolutely the case that our first point of care for women involves looking after them as best we can. The question of termination arises if it is part of the treatment that is needed.

I wish to put a question to the obstetricians. I understand that when a person with suicidal intent who is beyond a certain gestational period is being treated, efforts are made to made to induce the baby and save the baby's life. Are we saying prior to that gestational period being reached, the baby's life will be forfeited and the treatment will not take place?

I thank the Senator.

I am trying to find out whether the treatment that would be done post-viability could be applied to the earlier stage. As one of the witnesses said, a person who feels suicidal one day might not feel suicidal the next day. Could we try to bring the woman through such a situation to the gestational stage at which the baby could be induced safely?

Before I call Professor McAuliffe, I would like to acknowledge the presence in the Gallery of a former Senator, Dr. Mary Henry. I welcome her to this meeting.

A former Deputy, Geraldine Kennedy, was here earlier.

I did not see her.

I reiterate that we are talking about a small number of rare cases in which there is a substantial risk to the life of the mother. If we feel this risk can only be averted by the delivery of the baby - whether that is before viability or afterwards - that will be part of the care package. These decisions are made in conjunction with the mother, her family and a number of health care professionals. Of course we always include the life of the baby. If we feel we can prolong the pregnancy, absolutely we will do so. We may feel we are looking at a situation in which the life of the woman is in imminent danger, however. If the mother dies, the baby dies. If we can preserve the life of the mother, that gives the baby the best chance to continue. We take a team approach, including the family, when making these complex decisions. When the baby has reached any chance of survival, we always offer appropriate support.

I thank Mr. Niall Behan and Dr. Caitriona Henchion from the IFPA, Professor Robert Harrison, Dr. Meabh Ní Bhuinneáin and Professor Fionnuala McAuliffe from the Institute of Obstetricians and Gynaecologists, and Professor Richard Greene from Maternal Death Enquiry Ireland for being here this afternoon. I thank the members of the committee for their forbearance. I thank the Members of the Oireachtas who are not members of the committee for being here. I understand Professor Harrison would like to make a brief comment in conclusion.

This has been a somewhat disparate session compared to the sessions earlier in the day. I thank the committee for inviting us to the meeting. As the corporate entity representing the obstetrics and gynaecology specialty in Ireland - we will be most intimately connected with the administration of the legislation or regulations that must come into being, in our view - the institute hopes to be invited to engage actively on this issue by providing input and support to the Department of Health.

I thank Professor Harrison.