Ms Mary Leahy:

The moratorium of a few years ago was the most destructive instrument ever waved at the health service. It was unmanaged and crude in that it was financially driven. Posts were simply eradicated to meet budgetary constraints and no regard was had to the expertise being lost to the health service. As a result, there are pockets of deficits. There is no universal service nationally. Services in one area will excel in a particular way, while in others there will be deficits. Students may be mentored well in some areas, but in others it will be to their detriment. There is no uniform approach. I have mentioned that there is a huge deficit in clinical-educator ratios. The ratio should be 1:15 for clinical educators in the workplace, but that is not happening. We are possibly at half of that ratio, with the result that students are not receiving the support they need. I have also mentioned that staff deficits mean that staff are not freed up. Staff involved in midwifery care are under pressure from the point of view of the fact that one has direct entry undergraduate midwives entering the workforce and looking for placements and to gain clinical skills, while there are also postgraduate midwives, general nurses who have undertake a maternity service placement and student public health nurses who undertake a maternal and child module. As such, staff are under a great deal of pressure to provide mentoring, but the numbers are just not available to provide it.

In relation to the strategy, Deputy Alan Kelly asked if there was evidence of money being provided locally. I can speak for the community and say there is no such evidence. There has been a move where I work to provide antenatal care in the community, but that was happening pre-strategy and I cannot credit the strategy with it. My colleague, Ms Gorman, might be able to answer the Deputy's question in greater depth.

I was asked about community midwifery service differentials. I think I answered that question. There is no uniform approach; everything is based on the availability of resources.

If there is any question I have not answered, the Deputy should feel free to say it.

Deputy Billy Kelleher is not here, but I will address his questions. He mentioned the issues of recruitment, retention and career pathways, in particular. Career pathways constitute one of the major issues in recruiting and retaining nurses. There are no career pathways. Senator Alice-Mary Higgins mentioned the pathway leading to management. I agree with what she said.

There is a grade in nursing and midwifery, the advanced nurse practitioner and the advanced midwifery practitioner, and we have suggested a certain number of those be recruited but we do not have near the number we have recommended. There is no satisfactory pathway, therefore, unless one goes into management and many practitioners do not wish to take that route. The HSE will tell the committee later that it is recruiting but we are 350 nurses and midwives down on the end of last year, not the end of 2016 but the end of 2015. Although there might be recruitment there is also a huge attrition rate, because staff are not staying. The career pathway is definitely an issue and it must be developed.

On the question about when we will be able to provide a safe maternity programme, I have a simplistic answer to that. It depends on the resources in staffing. There is a strategy that recommends a ratio of one midwife to 29.5 births, but we are nowhere near that. We cannot say we have a safe practice until we reach that level. There is also a problem with staff midwives not being released for continuing professional development or education, which is vital in a profession such as nursing and midwifery where things are changing all the time. One must keep abreast of that. It will be when midwives are released for education and career development, when we reach the ratios required and when we have really good governance, which we are moving towards. We welcome the directors of midwifery in the 19 units.

There was reference to women's health and home birthing. That has been addressed, although Mary Gorman might wish to comment further.

On education programmes provided for women from the conception stage, that could improve significantly. It must be brought into the schools. Many women will encounter unplanned pregnancies and at that stage, without wishing to be crude about it, the horse has bolted. There is huge room for health promotion. In fact, health promotion suffered hugely in the last number of years because the service has become reactive rather than proactive in many areas of practice.

Senator Higgins mentioned concerns about recruitment and retention. I believe I have responded to that.