Ms Mary Leahy:

In 2014 we surveyed the number of midwives and the information was provided by employers. There were 1,849 midwives, which gave a ratio of one midwife to 38 births, based on a total of 70,879 births. At the time 554 midwives were needed, but two things have happened since. The birth rate has decreased slightly and a strategy has evolved which recommends a ratio of 1: 29.5. We have a long way to go to reach that ratio.

The issue of recruitment and retention has been mentioned. We have significant problems in that regard. In our opening statement we mentioned that we had a problem with the undergraduate programme. There is a high attrition rate from the direct entry midwifery programme. Committee members may not be aware that traditionally people became general nurses first and then went into midwifery; therefore, they got a good introduction to health care in general. They worked in a hospital and then sought midwifery placements. As a result, they knew going into it what was ahead of them. Direct entry to midwifery is somewhat more difficult for students in that they do not necessarily have knowledge of what they are going into. It is highly pressurised, an area which has been under the microscope in recent years, with many negative reports, including the report on services in Portlaoise. It involves a high level of litigation and high risk. The pressure on students is extreme. This is coupled with the fact that there is a deficit in the number of qualified midwives, with the result that they are not freed to educate or mentor students. There is an attrition rate of 25% from the direct entry programme, which is extremely worrying. In some pockets the attrition rate is as high as 40%. Students are leaving the four-year degree programme in the third or fourth year because the pressure is too much.

Another problem I must highlight in this area affects clinical placement co-ordinators - clinicians who are working with student midwives to educate them in clinical skills. The recommended ratio is one clinical placement co-ordinator to 15 students, but we are nowhere near this figure in the Irish health care setting. Student midwives do not receive support and are not being mentored; as a result, they find the area pressurised. We also have anecdotal information that direct entry students are working in part-time jobs to support their education and are being harvested into areas such as retail, which is worrying. They are qualifying or coming near to it, but they do not practise. They are being offered salaries in the retail sector or other non-midwifery areas which exceed that which a midwife earns. They may also have company cars. Midwives ask why they should take a position where they would be at risk of litigation on a daily basis, with their licence exposed, in a pressurised and stressful role when they can take something much easier.

In our opening statement we alluded to the difficulty in seeking postgraduate placements. We have called for an increase in the number, but we must acknowledge that many such placements are not taken up by students. There are a number of reasons for this, one of which is we are very short of nurses. To reply to Senator Colm Burke, there is a distinction between nursing and midwifery; they are two separate professions. Many nurses who wish to move into midwifery are not released to pursue education in midwifery because we are short of nurses and employers will not fund such education because of budgetary constraints. A postgraduate midwife will qualify after undertaking a four-year undergraduate nursing degree programme and an 18-month postgraduate midwifery programme. Those who ordinarily undertake this programme have identified that when they complete it, they will not gain experience and will not be recruited. If they have a lack of experience, they have poor job prospects. They are asking what is the point of undertaking the midwifery programme when they will not be recruited at the end of it. Many of those who have come through the postgraduate system have returned to general nursing and do not use their midwifery qualification, which is huge concern.

The answer is we must produce our own midwives. We have to increase the number of undergraduate and postgraduate placements. The midwives who complete the undergraduate programme perform very well in the workplace. They are possibly in pockets in which they receive support and mentoring, but there are also pockets in which there is no support or mentoring.

Deputy O'Reilly asked what is needed. We have to grow the strength of our own midwives and we need to attain a critical mass of them in this country. She asked whether we need legislation to underpin this, but we must grow midwifery and reach a critical mass first. Legislation will be warranted further down the line, but we have much work to do. We are greatly concerned that we are a year into the strategy and we do not see any evidence of recruitment. We would welcome the rolling out of the provision of directors of midwifery in the 19 units. Heretofore, many units did not have directors of midwifery, and if they did, they were often directors from a nursing background, not a midwifery background. We have a lot of work to do in recruiting. We cannot recruit midwives from abroad for a number of reasons. They are often not there, and if they are, we have a very high standard of education in Ireland so there is often a deficit or a difference in educational standard.

Deputy O'Reilly also mentioned community midwifery and primary care. I am a registered midwife but I work as a public health nurse so I am in community and primary care. I am fortunate enough to be in a world-class purpose-built primary care unit. The problem with it is that it is so busy that it has only been open for three years and we actually find it hard to get a room within our own building because the level of turnover is massive, although the turnover is great to see. The antenatal programmes have reached that primary care centre, so mums - this is all about mums - now have their antenatal care in a primary care centre. Then, as public health nurses, we provide the postnatal care in the exact same centre, which is very close to the mums' residential areas, so the care is delivered in the community, which is to be welcomed.

What is to be done? Deputy O'Reilly almost answered the question herself. We need far more primary care centres and they need to be rolled out very quickly. Some of my colleagues work in single inappropriate facilities with a lack of IT and care-taking facilities. This is not appropriate as a clinic for antenatal women. If we had the infrastructure rolled out in the community - we have been talking about this for far too long - it would help a lot in bringing more antenatal care into the community. We also have the domino scheme, to which Dr. Boylan alluded. We had a domino scheme in Galway and it was taken away because of lack of funding. However, we have an early discharge programme in Galway whereby the midwives take on an average of four to five mums who have delivered their babies home to the community within perhaps 24 hours or at most 48 hours. The midwives care for them in the community perhaps for the first five days and then hand care over to the public health nurse. In this regard, it was a very retrograde step that midwifery was taken away as a necessity for public health nursing education because if midwifery were brought back for public health and community midwives came out for the early postnatal period, this would help us to reach our critical mass.

Deputy Burke, or Senator Burke, rather - I apologise, I have elevated him - mentioned support. I have gone some way towards answering his question with the points I made about the lack of a clinical co-ordinator for the student. The supports are not there for the students coming through the system, but they are not there for the midwives on the ground either. The nature of midwifery practice is that it is quite challenging. There are many unforeseen and emergency situations. It is underestimated by our management system, and the staff are not on the ground to take time to process some of the harrowing events being dealt with in the workplace. The Senator mentioned the 19 directors of midwifery and that eight posts were not filled. I am not clear on the numbers, so perhaps my colleague will take that question.

Deputy O'Connell made a comment on why gynaecology was not included in the strategy. My colleague, Mary Gorman, was a member of the strategy so, again, she might take those questions. If there are questions I have not answered, I ask members to feel free to come back to me again.