Dr. Krysia Lynch:

I thank the members for their interesting comments and questions. I will not address staffing levels - obstetric, NCHO or midwifery staffing levels - as that is not my area of expertise.

Deputy Murphy O'Mahony asked about pre-conceptual care. She highlighted a very interesting aspect of maternity care, which is what the woman or the family experiences. This experience is a continuum. It is very easy for those involved in planning for services or delivering a particular part of the service to see just their area, or to see it broken down into very convenient slots. For a woman and a family it is a continuum which might have started when the woman held a doll when she was five years old, thinking she might like to have a baby one day, and later finding out that maybe there are difficulties along the way. Women report that issues associated with sub-optimal fertility or issues associated with fertility that they encounter can be difficult because often it is necessary to use a private service, which is not equitable. Women who are medical card holders or who cannot afford private care find that waiting lists in the public service are very long, and that it is necessary to fulfil certain criteria. For example, women can be older if they are can afford private care but must be younger if they are in the public system. That is one issue women report.

Pre-conceptual care is best addressed in the community. Most community care associated with pregnancy and childbirth is a one-to-one between a woman and her GP. Women who are healthy may not go to their GP very often, so they may not have that connection. The national maternity strategy recommends an increased provision for community midwifery, not just in attending births, but having a community midwife in a doctor's practice. These midwives could engage with areas of society which are more difficult to engage with and which we know have poor engagements with health, with different women's groups and with different ethnic minority groups which may not have those close connections that perhaps women born in Ireland would have with their GP. The greater emphasis on community care and community midwifery care in the strategy could address this issue. In the UK, it is common to have a midwife in every GP's practice which we do not have here. Our GP practices are moving from practices with one GP to practices with several GPs and a midwife. There is an insurance issue there. It is possible to obtain insurance for a GP to have a practice nurse, but not necessarily a practice midwife. That is something that can be looked at.

Of the four witnesses here today, I was the only representative on the national maternity strategy steering committee. The steering committee was presented with a series of definitions and terms of reference. Looking at fertility and gynaecology was not within our remit. It was already presented to us de factoat the very first meeting that they would not be included. I am not certain as to the reasons, as they were beyond our deliberations.

Professor Kenny has alluded to the fact that a scan is a choice.

Not every woman chooses to have a scan. Not every woman would choose to have an early first trimester scan to find out if there were any issues associated with the pregnancy and not every woman would choose to have an anomaly scan where she has an opportunity to have one, so we always have to bear in mind that not everybody necessarily wants to know. Even though we, as advocates, or the medical profession may think it is unusual, some women do not want to know.

I first came across scans, and issues associated with scans, in the miscarriage and misdiagnosis furore that erupted in 2010 where we started to see that there was great inequity in terms of scans, scanning equipment and the ability to understand and diagnose things from scans. My understanding is that our capacity in that area in terms of training has unquestionably improved and that when the capacity is there to actually perform the scans we have the expertise, as Professor Kenny said. We have adopted things like early pregnancy assessment units where women who are perhaps experiencing question marks around their pregnancy do not have to sit in the same area as women who are having a full term, happy pregnancy, if one likes, so we have those issues.

On the questions associated with abortion, we have reports about first trimester scans where women feel that in certain units they are not being offered a foetal scan, an early scan, but I do not think that is really the case for the second trimester scan.

There was a question about breast-feeding and I would like to say something about that before I let my colleague respond to the rest of the questions. It is very interesting because there are so many different rates. If one were to Google "breast-feeding Ireland" the very first thing that will come up from the search is a web page that is monitored and run by an artificial formula company. That indicates some of the issues associated with breast-feeding in Ireland. Our rates hover around 50% and the initiation rates are much better for some units than others. Although he has left the National Maternity Hospital, Dr. Boylan can take a bow, since it celebrated a 72% initiation rate this year which is very high but it can be as low as 40% in other units.

The Polish contingency, and having a Polish background I wave a little flag there, are possibly responsible for some of those rates in certain areas of the country. However, when AIMS ran its survey, one in four women indicated that she found her breast-feeding support as poor or very poor in hospital. What does that mean and why is that? One of the key issues was that there was not lactation consultants on duty during out-of-office hours. Unfortunately, babies do not just want to feed in office hours, they want to feed at the weekend and in the evening and mothers give birth in the evening and over the weekend, so that is an important issue that needs to be addressed in terms of staffing. Also, and I suppose this is a staffing issue, post-natal wards are extraordinarily busy. Some post-natal wards in the busy hospitals in Dublin will have a midwife to woman ratio of 1:18. We have a huge number, and an increasing rate, of caesarean sections, with more medicalised births - more or less one in three - so those midwives are having to deal with women who require pain medication, women who are perhaps recovering from surgery and they have to triage. Breast-feeding a woman on her third baby will probably be lower down a list for a midwife's attention. Increasing the number of midwives, especially in post-natal care, is very important.

If we look at the rates from hospitals, they are about 50% but if we look at the audits that have been done on community care it is different. If one looks at the annual home births audit for Ireland, which is carried out by the National Perinatal Epidemiology Centre in University College Cork, for example, the initiation rate is 99.7% and the continuation rate at discharge, which is between two and six weeks, is 97%, so that follows on from Professor Kenny's response that community midwifery is very important and perhaps different models of care are important because those same high rates are again replicated within midwifery-led care led options, although they are not quite as high.

My final point on breast-feeding is that we have issues with the World Health Organization's code of marketing of breast milk substitutes in Ireland. Artificial milk is available to mothers when it should not be and it is offered to women where there is no clinical reason for offering it. Those breeches of that code are part and parcel of the issue. For example, one can see bottles of formula just left around in post-natal wards but that should not happen. In conjunction with that, the WHO and UNICEF have established a baby-friendly hospital initiative which some Irish hospitals are signed up to, although some are not. I think the strategy recommends that all hospitals should try to achieve that status.