[Mr. T. O’Malley   ]
The inquiry found that management’s initial response to the revelations about Dr. Neary’s practice was prompt and appropriate. The decisions made and the procedures introduced to deal with the situation at the time were courageous and correct. Now most of the elements are in place and the importance of quickly completing the process has been stressed to the National Hospitals Office. The inquiry found that over 23% of obstetric hysterectomy records, representing 44 cases, for the period 1974 to 1998 are missing and were intentionally and unlawfully removed from the hospital. The inquiry is satisfied that a person or persons unidentified, who had knowledge of where records were stored and who had easy access to those records, was responsible for a deliberate, careful and systematic removal of the key historical records which are missing, together with master cards and patient charts. Alterations were made to the maternity theatre register after complaints were made against Dr. Neary. Most of the missing records refer to Dr. Neary’s patients. The Tánaiste has invited the Garda Síochána to read the report in order to determine whether any further action is warranted in the light of Judge Harding Clark’s findings. Among the many other disturbing findings is that a number of the patients were not told of their hysterectomies until some time had elapsed. Very few patients questioned Dr. Neary for carrying out a hysterectomy, but those who did found that his attitude became defensive and unfriendly when he was challenged. The most common complaint from patients was how the doctor carried out procedures on them without discussion beforehand. As for the hospital today, the inquiry found that the possibility of the maternity unit falling behind in current practice is now remote. However, we cannot be complacent regarding this finding and must ensure that all necessary measures are taken on foot of the report’s findings. There have been major changes in practice in the maternity unit to minimise or entirely remove the climate of isolation referred to in the Medical Council report. The incidence of peripartum hysterectomy has fallen precipitously and now accords with national rates. A team of consultant obstetricians is now in place, which should facilitate improved clinical audit and governance. The current consultants have developed a strong collegiate approach to practice. The unit is moving forward and offering care that is evaluated against known benchmarks. The inquiry found the medical board and the new consultants to have the motivation, skills and energy to move the hospital forward as a fully recognised teaching hospital with specialist registrar training in all its departments. The Tánaiste met the medical board following the publication of the report and was impressed with its obvious commitment to ensuring that the very highest standards of care prevail in the unit. Members of this House will agree that this is a most comprehensive and fair report but it is also clear that many lessons need to be learned and changes made to ensure that such events do not happen again in Irish hospitals. The findings and recommendations are being examined in detail by the Department of Health and Children, in consultation with the Health Service Executive, the Medical Council and the other professional regulatory bodies. The report’s recommendations will act as a significant catalyst for the reform agenda. They confirm the appropriateness of the actions taken in the preparation of the new medical practitioners Bill, the reform of the consultant contract and the changes in management systems in hospitals. They also confirm the importance of establishing the new health information and quality authority to set standards in health services and the provision of information, as well as to provide an early response to any suggestion of systems failure. We owe it to the women affected by the events outlined in the report to learn lessons quickly and to put in place safeguards to prevent recurrences in any hospital. Ms Terry: I welcome the Minister of State at the Department of Health and Children, Deputy Tim O’Malley. I welcome the report, published by Judge Maureen Harding Clark on peripartum hysterectomy at Our Lady of Lourdes Hospital, Drogheda. It makes shocking reading as the judge said. I sympathise with those women involved, who were violated in a most appalling way. All Members, both women and men, must have great sympathy with them. The appalling substance of the report is that these practices were allowed to happen and continue for several years unchecked. One man in particular, Dr. Neary, was in a position to be able to carry out those acts. For many young women hoping to have several more children, the consequences were devastating. It must not be forgotten that older women were also involved. Unnecessary peripartum hysterectomies carried out on those women were crimes. We must now ensure they get some satisfaction as a result of the report’s recommendations. We must also ensure no other woman, man or child, ever suffers at the hands of a medical person. Putting in place the report’s recommendations will help to ensure it never happens again. From my experience, and that I gained from listening to my mother, the culture surrounding Dr. Neary also surrounded many other consultants. Many, but not all, always had an arrogant air about them. They were the lords and no one could question them. At Our Lady of Lourdes Hospital, no staff member dared question a consultant. If a staff member did, he or she suffered for it. Although many must feel sorry for not questioning the events in question, at the time they would have lost their jobs or been barred from promotion. People in authority at the hospital knew what was done by Dr. Neary was not right. Many of them have a responsibility to face up to what was done. They have a case to answer which must be properly investigated and people must be held accountable. Many young medical professionals have a different attitude from that of senior consultants some years ago. They do not have that air of superiority about them; they keep the patient’s interests to the fore. Unfortunately, some aspects of the culture still exist. The structures we put in place must weed out those consultants who think themselves as gods in the hospitals. They must be reminded that they work in the public sector, are paid by taxpayers’ money, and must work for the public. They have a duty to look after the patient first. Structures and proper audits must be in place to ensure consultants are held to account. George Bernard Shaw once said, “Every profession is a conspiracy against the layman”. Some years ago that charge could be laid against the medical profession. I fear the culture of superiority has still not gone away. Did the report consider if there were differences in Dr. Neary’s treatment of public and private patients? From my experience, I know there is one. One will still notice the difference between treatment meted out to a public and private patient in hospital. I was first pregnant when I was 20 years old. Living in Dublin with no family around me or a GP, someone at work advised me to present at a certain hospital. I will never forget the treatment I received as a public patient at that hospital. When I came out, I told my husband I was never going back to it, that there must be another way of being looked after. Along with many other women, we were put into cubicles, set up on the high stools with our legs splayed out. The senior doctor came along with his trainee. To them I was just an object, I was not even spoken to. I had an internal examination from the senior doctor. He then turned to the junior doctor and said, “Now, you have a go”. That was my experience of having my first baby as a public patient.  12 o’clockI was lucky that my husband and I could manage, but with some difficulty, to join the VHI. From then on, I went private. My next visit to a consultant was held in a private room. It was all very nice, like going to a hotel and being treated with respect. My experience of the difference between public and private treatment was no different from that of many others. Although I had my last baby in 1981, when I pass a hospital it often crosses my mind how public patients who are pregnant are now treated. Private female patients can have a sterilisation carried out because they can afford it. The Minister of State said An Bord Altranais carried out assessments of Our Lady of Lourdes Hospital. In 1980, it advised that women should be offered a full choice on contraception and that midwives should be trained in these methods. That is not good enough. I want to ensure that happens. Not long ago I asked for a debate on sexual and reproductive health in this House. Such a debate is still necessary. Sterilisation should be available to every woman if she wants it. We are talking about patient choice and making that service available. While these issues may be relevant indirectly to the report, they must be examined when we are dealing with the recommendations in the report. Religious ethos should not be a factor in a patient’s treatment in hospitals that receive State funding. It is taxpayers’ money and if a patient requires a particular treatment he or she should be given it. Religion should not come into it. In a recent case in the Mater Hospital religious ethos was a factor in whether women should get certain treatment if they were taking contraceptives. That is dark ages stuff. I am glad that issue was resolved at the time. The report focuses on what was done to women at a time when they are more vulnerable because they are pregnant. Women at that time put their trust in the medical profession — the doctor treating them, the nurses and the anaesthetist. Many of them had great respect for Dr. Neary. They believed he looked after them but we now know that in many cases he did not or he had some ulterior motives, on which I am still not clear. This report does not explain the reason Dr. Neary carried out so many of these type of hysterectomies. Despite the excellent report on the failures of the system within the hospital, I still do not understand the thinking behind Dr. Neary’s actions. Dr. Neary’s victims need to know that. We all need to know his motives. Any structure that is put in place to ensure this does not recur must provide that a person who has any knowledge of wrongdoing has the ability to come forward with information and that they will be protected, regardless of whether it is a nurse starting off her training or the most senior person in the hospital. A person wishing to make a complaint must have somewhere to go to with that complaint. The complaint must be dealt with and they should not be treated in the fashion the people in Our Lady of Lourdes Hospital were treated. I am concerned there may be other cases like this one of which we are not yet aware. Ms O’Rourke: Yes. Ms Terry: They may not be maternity cases but may concern other areas. It may be women with breast cancer having their breast removed unnecessarily. Who knows the other cases that will come to light down the road? It is vitally important, therefore, that we have structures in place now and if they are not in place, that should be done at the earliest opportunity to ensure this never happens again, that the victims get the compensation they deserve as quickly as possible and that we do not make them suffer any more than they have done already. Looking after these women must be the number one priority, and that must be done as speedily as possible. Ms Feeney: I welcome the Minister of State to the House for this important debate. I am delighted the Upper House has an opportunity to debate what the Minister described as an excellent, fair, comprehensive report. We thank Judge Maureen Harding Clark for the speedy report she has presented. Before I begin I want to congratulate Patient Focus, particularly Sheila O’Connor, who stuck with this issue and counselled very vulnerable women when nobody else was available to listen to them. I am aware of the personal circumstances of the Neary women because I sat on the Medical Council’s inquiry which lasted three years and I have a particular knowledge of events covered in Judge Maureen Harding Clark’s report. I listened with great sadness to the story of the victims of Our Lady of Lourdes Hospital. As a woman and a mother, I empathise greatly with the pain and suffering that was so evident in all their stories. Some of these women told their stories ten years after the event. I remember thinking at the time that it could have happened yesterday, last week or last month because the pain was so evident in the voices and faces of these women. The Medical Council acted swiftly in December 1998 when it received the prima facie evidence from the health board at the time. It went to the High Court to obtain a section 51 order under the Medical Practitioners Act. Section 51 of the Act will render a doctor unfit to practise and he will be taken out of commission pending a full Medical Council fitness to practise inquiry. Following that inquiry, Dr. Neary was struck off the medical register, and rightly so. Michael Neary was a deeply flawed practitioner whose actions were unforgivable. Senator Terry said we have to know why he acted as he did. I attended that inquiry over a three year period and on many occasions I looked across at the man to try to gain some insight into what might have gone wrong for him but I saw no remorse nor did I gain any insight. When women broke down giving their evidence, I bit the inside of my lips and felt a lump in my throat as I held back tears. I find it difficult to talk about it even today. Their stories were horrific. In the nine cases I heard, not one of those women had a hysterectomy for sterilisation purposes. They ranged in age from a teenager of 19 having her first baby to a woman of 32 years of age. Women today do not even start having their families at 32 years of age. On the high number of caesarean hysterectomies carried out by Michael Neary — I will continue to call him Michael Neary because it is a shame to the profession of medicine that this man was called “Doctor” for so long — I was told by Dr. Eamon McGuinness, an obstetrician-gynaecologist who sat on the inquiry with me, that in his 30 years of practice he had carried out one caesarean hysterectomy on a woman in her mid-30s who had five children. He worked on that woman for eight hours. He massaged and packed the uterus and did everything medically possible to try to preserve it. She received 11 or 12 units of blood and, after nine hours, the doctor called in one of his senior colleagues to help with the operation. I tell this story because Dr. Neary never called in any of his colleagues to help. He proceeded to perform a hysterectomy within minutes of delivering babies. The babies were delivered, the hysterectomies were carried out and the women were back in recovery within an hour to an hour and a quarter. The hair is standing on my head recalling the horrific events about which I have heard. It is worthwhile recalling a few of the women’s stories. I will not name any of them but I will never forget their names. The first woman I want to talk about delivered a little baby girl on 18 August 1986. One might ask how I can remember the date; I remember it because my fourth baby, a daughter, was born the very same day in the north west in Sligo General Hospital. I was ten years the woman’s senior — she was 19 and I was 29. My baby was born perfectly healthy at 7 a.m. and the woman’s little baby girl was born at 2 p.m. Her baby, who was called Eileen, had spina bifida and died six weeks later. I will never forget the mother’s tears and those of her husband as they told us their stories. She is still married to her lovely husband but her life is a living hell. She has been robbed of the most vital thing any woman has, that is, the facility to procreate. Another lady, who lost her first baby at 23 weeks, had her second baby delivered by Dr. Neary at full term. She begged him from the operating table not to carry out a caesarean hysterectomy. She had asked her husband before her baby was delivered not to let the doctor take away her womb. Dr. Neary told her, after delivering her little baby boy, that he had to proceed to hysterectomy within ten minutes or she would die. She felt perfectly well and there was no way she would have died within ten minutes, as he told her. He told her husband that if he did not sign the consent form she would be dead within ten minutes. The other midwives all knew the woman and one cried and asked the doctor to go for Dr. Lynch, but Dr. Neary said the woman would be dead if the hysterectomy was not carried out immediately. I query the consent Dr. Neary received to remove any of these uteri. I do not believe he had consent but that he robbed the women of their uteri. When the Medical Council conducted its inquiry, I spoke on “News at One” and stated the report should be handed over to the Garda and that a criminal investigation should be carried out. Another story concerns a lovely young girl in her late 20s who delivered her third baby. In this case Dr. Neary also proceeded to perform a hysterectomy. The woman did not want to be involved in the Medical Council’s inquiry and we respected that. However, when Dr. Neary gave evidence and it was adduced by his senior counsel that the lady was a Jehovah’s Witness, and that, for religious reasons, she had asked that blood not be given to her and that her uterus be taken, if necessary, I could not sit and listen to that kind of evidence. I asked that the lady be subpoenaed and when she came before us her evidence directly contradicted that of Dr. Neary. I tell these terrible stories to afford Members an insight into what occurred. On reading the report one would never know the horrific nature of the procedures to which the women in question were subjected. I mentioned Sheila O’Connor earlier in my address and I am delighted to see her and some of the women from Patient Focus, who have been affected by Dr. Michael Neary, in the Visitors Gallery. They are very welcome. How and why did these procedures on the part of Dr. Neary occur? We will never know and I do not believe anybody will ever get through to that man’s mind to know why. This is poor consolation to the women affected. We all know pregnancy and the birth of a baby comprise a very joyous occasion. Pregnancy is not an illness but a condition one enjoys from the minute one is told one is carrying a baby until one delivers it. Pregnancy represents a family time, but the women in question have been cruelly denied the possibility of ever experiencing it. There are women who have had one baby but who will never have another. I know of one woman whose little baby girl died and she will never have another to replace her, not that one can ever replace a child. I find this very upsetting. As I said to Sheila O’Connor last night, I have had sleepless nights for the past week and had them all through the inquiry. If that is how I am feeling, how in the name of God are the women Dr. Neary butchered and violated feeling? What happened to them is beyond belief. They have been let down by us all, and such a system should never have been in place. Dr. Neary played God and nobody ever said to him he could not do so. The sisters who ran the hospital looked up to him as God, as did the junior staff he was training. On reading the records of the women involved in the nine cases I know about, I noted that Dr. Neary really did play God with them. He wrote in their charts statements such as “Lucky to survive the night”, “Thank God I was able to save her”, “Got away with this one — baby and mother alive” and “Uncontrollable bleeding, couldn’t stop it, spent all night in theatre”. I know that none of this was factual. Dr. Neary never spent all night in the theatre and there was never any uncontrollable bleeding, as we now know. The people to whom I really point a finger are Dr. Neary’s senior colleagues, the pathologists and anaesthetists, who should not have been afraid to address the matter. The anaesthetists were in the delivery rooms and operating theatres and saw there was no raised blood pressure or increased pulse rates and they knew the women would not die in 15 or 20 minutes. The pathologists who examined the uteri and sent them back to Dr. Michael Neary saying no abnormality could be found in them have many questions to answer. The “three wise men” sent to Our Lady of Lourdes Hospital by the Irish Hospital Consultants Association — Drs. Prendiville, Stuart and Murphy — issued a report giving Dr. Neary a clean bill of health, as implied in Judge Harding Clark’s report. She adduced that they did so out of congeniality and compassion for Dr. Neary. They must have told her so. Shame on those men. If I had a stronger word or if I were permitted to use offensive language in this Chamber, I would certainly use it in respect of them. Shame on them. If a man had a minor procedure carried out on his reproductive organ and he emerged from the operating theatre minus that organ, there would be outrage. It might happen once but would never happen 188 times. The women in question were vulnerable and were robbed of their internal reproductive organs. There is no other word but “robbed”. Can it happen again? Unless we change the Medical Practitioners Acts, it will happen again. It is possible that it is already happening in another discipline. I am aware of the Tánaiste’s interest in this matter because I have spoken to her. I compliment and praise her on the humane way she has dealt with it since the publication of the report last week. I note that Ms Sheila O’Connor of Patient Focus, who is in the Visitors Gallery, is nodding her head. Patient Focus has been in contact with the Tánaiste on many occasions. I am confident the Tánaiste will act effectively and efficiently to bring legislation to both Houses so that there is change in this regard. I am sure I have gone over time. Acting Chairman (Mr. Dardis): I am reluctant to stop the Senator, but her time has concluded. Ms Feeney: I will conclude because other Senators have as much to contribute as I have. Ms O’Rourke: We do not have the same insight as the Senator. Ms Feeney: I am glad that Judge Maureen Harding Clark has pointed her finger at the people at whom I have pointed my finger — the anaesthetist and the pathologist. Her recommendations represent a blueprint which should be taken on board by all medical specialties in all hospitals. There needs to be a change of attitude so that the medical profession cannot continue to lord it over members of the public. I could speak for another hour on this matter, but I will conclude by thanking Judge Maureen Harding Clark for her great report and wishing her well in her deliberations on the redress issue. From the bottom of my heart, I wish the women affected well with the rest of their lives. Acting Chairman: I congratulate the Senator. Dr. Henry: As Senators can imagine, it is difficult for me as a member of the medical profession not to hang my head in shame, having read this report and listened to the contributions of Senators Feeney and Terry, as I speak in front of some of those who have been so grievously injured by a member of my own profession. No adequate reason can be given for the behaviour of Dr. Michael Neary. This has been an appalling tragedy. I am glad that the Minister of State, Deputy Tim O’Malley, apologised on behalf of all of us, not just to the women in question but also to their families. The women and their husbands were denied children, their parents were denied grandchildren and the children they already had were denied siblings. A substantial number of people were affected by the appalling operations that took place at Our Lady of Lourdes Hospital in Drogheda. Whoever stole the huge volumes of birth registers and charts which comprised the maternity theatre register should send them back at once, anonymously if necessary, as I am sure they have not destroyed them. The charts in question are of great importance to the 44 women to whom they relate, not just as they take legal cases, etc., but also as they try to get some kind of satisfaction in their attempts to find out exactly what happened. The registers contain details of the stillbirths which took place during the period in question, which means that women who had stillbirths at the hospital during that time are not in a position to register their cases. A national stillbirth register has since been put in place, fortunately. I assume that the theft of the registers and charts was done by someone with a misguided sense of loyalty to Dr. Neary, but it was a dreadful thing to do. They should be sent back at once. I hope the Garda investigation into the robbery will be satisfactory. The commission that inquired into the practices at Our Lady of Lourdes Hospital has done an incredible job. I compliment Judge Maureen Harding Clark on what she has done. Not only did she have to deal with the information she could get, but she also had to try to cross-reference it with other records to ensure that each of the horrific number of the cases was accounted for. The vast majority of cases involved Dr. Neary although some of them involved Dr. Finian Lynch. During the period in question, an excessive number of peripartum hysterectomies was carried out at Our Lady of Lourdes Hospital, compared to any other hospital in this country or any other part of the world. It beats me how members of the medical profession who were working at the hospital at the time can say they did not know anything unusual was happening. The issue of gender has been raised in the context of the debate on this report. The membership of the Institute of Obstetricians and Gynaecologists during the timeframe under discussion was almost entirely male. The men in question were in a position of great power, whereas a degree of hierarchical obedience was expected of the women involved, who were either patients or nurses and were in a subservient position to the consultants. Ms O’Rourke: Yes. That is my point. Dr. Henry: Our knowledge of the hierarchical structures which were in place does not make the whole procedure any less inexplicable. It is most unfortunate that those who inspected Our Lady of Lourdes Hospital were Dr. Neary’s peers. Ireland is a very small country with a small number of obstetricians. That there were under 100 obstetricians in the country at that time meant that such people were inspected by their friends, which was entirely unsatisfactory. When the Royal College of Obstetricians and Gynaecologists carried out inspections, they were carried out by its Irish members, which was also unsatisfactory. I share Senator Feeney’s grave concern about the fact that three obstetricians gave Dr. Neary a clean bill of health, as it was described locally, in 1998. That caused enormous distress to those in the local area who had objected to his conduct. If peer review is to be meaningful, it needs to be impossible for people to be reviewed by their friends. Some people objected to the procedures which were taking place at Our Lady of Lourdes Hospital. The hospital matron deserves great credit for making an objection. Midwives, including young student midwives in some cases, objected to the old-fashioned practices of Dr. Neary, who had never been retrained and had been appointed at a very young age, after limited training in the United Kingdom. Despite their criticisms, Dr. Neary was still able to make midline incisions for caesarean sections, to practise shaving and to examine women in the lithotomy position, as Senator Terry so well described. The people who raised concerns were told that their complaints were unjustified. They had to withdraw their complaints in tears. The anaesthetists are criticised in the report, which states that they should “recognise their professional obligations to fill in clinical incident forms” in the theatre when untoward events occur. As I was reading the report, I started to wonder whether things went on in the Rotunda Hospital, where I worked for three and a half decades, which I simply did not realise were happening. It happened on three occasions that two peripartum hysterectomies were done in a single day at Our Lady of Lourdes Hospital without anyone taking any notice of it. When I worked at the Rotunda Hospital, such a procedure was second only to a maternal death and everyone in the hospital would know about it. I was relieved when I read the section of the report which mentioned that Dr. Peter McKenna, who is a former master of the Rotunda Hospital, had examined the incidence of peripartum hysterectomies between 1975 and 2001 and found that 52 such procedures took place in the hospital, which had an annual average of over 6,000 deliveries, during that time. Just 52 peripartum hysterectomies resulted from the many thousands of deliveries which took place in the hospital over that 27-year period, whereas there were 188 such procedures in the Our Lady of Lourdes Hospital, which had a much smaller overall number of deliveries in that time. The staff of the maternity unit at Our Lady of Lourdes Hospital seemed to feel that loyalty to the unit was more important than loyalty to their patients or to the medical profession. They were under the impression that Dr. Neary, who I accept was a hard-working man with a very heavy workload, could not fail to do the right thing. It is suggested in the report that the nuns of the Medical Missionaries of Mary thought that Dr. Neary “walked on water”. There are great dangers in small units; for example, there might not be anyone there of sufficient seniority to query the practices which might be taking place. When the matron complained to her colleagues in the unit, she was told by the consultants that it was none of her business. There seems to have been a bad atmosphere between the unit’s consultants and the rest of the staff of the unit. The hospital’s culture meant that no advice regarding contraception could be given. No tubal ligations could take place, for example. Ms O’Rourke: Why? Dr. Henry: I knew some of the Medical Missionaries of Mary quite well because they used to accompany me to meetings in London and elsewhere. They were kind and good women who were very determined in their religious beliefs. The mixture of religious beliefs and human reproduction can sometimes lead to serious situations which are perhaps not to the advantage of patients, who may not share such religious convictions. The Minister of State said that “patients require assurances that their interests are paramount and override any sectional concerns”. That principle should be at the forefront of whatever happens. When Dr. Neary arrived in Our Lady of Lourdes Hospital, it was one of the major hospitals in the country for carrying out symphysiotomies. The others were the National Maternity Hospital in Holles Street and the Coombe Hospital. I do not know the exact number of symphysiotomies that were carried out in the hospital, but I have been at meetings where patients wept about them to me. This procedure was carried out by cutting the front of the pelvis to allow a vaginal delivery, rather than carrying out a caesarean section. Therefore, there was a culture of applying the Catholic ethos in a very strict manner when Dr. Neary arrived. He claims that this fact was important in explaining why he carried out so many peripartum hysterectomies, but this claim cannot be taken seriously. It is true that he objected and was allowed not to take part in tubal ligations in England, but when he arrived in Our Lady of Lourdes Hospital, both he and Dr. Lynch asked the Medical Council and the Medical Defence Union about the situation regarding tubal ligation, and they were told they would have to abide by the ethos of the hospital. We should recall that these issues were not just due to the ethos of the hospital, but to the culture at the time. That is why the pathologists frequently reckoned that the perfectly normal uteri they examined were being removed for sterilisation purposes. These procedures were referred to as “compassionate hysterectomies” in the report. The figures at the Coombe had to be revised upwards when Dr. James Clinch became master there. He added another 70 cases to the list of what was described as compassionate hysterectomies. There were no pathological problems, yet serious operations were carried out to remove the uterus. I was appointed to the Rotunda Hospital and to Sir Patrick Dunne’s Hospital to look after women who had previously suffered from deep vein thrombosis. This can occur when a person gets a clot in the legs which goes to the chest and it is still a high cause of maternal mortality, but it is nothing like it was then. It occurred much more frequently to women who were older and who had many pregnancies. I looked up the maternal mortality figures for the years 1966 to 1973. A total of 23 patients had died from pulmonary emboli in those years. Their age and parity for a sample went as follows: age 33, 11 children; age 40, 12 children; age 43, nine children; age 42, 13 children; age 31, eight children; age 33, 12 children and so on. |