Ms Breda Kerans:

Senator Colm Burke mentioned staffing numbers. I come from the west of Ireland and from a rural perspective, it is a huge issue and retaining staff is a huge issue. I know it is an issue for all the hospitals but there is quite a dependency on agency staff which has a knock-on effect across the board and it is certainly a safety issue. AIMS would like to see the dependency on agency staff reduced dramatically. Other countries have addressed this issue in rural areas, particularly when, as in the west of Ireland, there is a small population which widely dispersed. Countries such as New Zealand, Australia and Canada have put in place specific strategies in order to retain staff in those areas. For example, one strategy that most of those countries have put in place is that when staff come from abroad, they are obliged to spend a certain amount of time in a rural hospital before they can go to the larger teaching hospitals. They have also employed strategies around staff rotation in order to keep competency levels at the required level, so that somebody is not necessarily working in a rural hospital for prolonged periods of his or her career and that is something AIMS mentioned in its submission to the maternity strategy and which we would like to see considered because it is happening in other countries.

Hospitals in rural areas, and particularly in the west of Ireland, have probably the lowest levels of anomaly scanning, unfortunately, and that lack of access to anomaly scanning is reflected in many of the cases that have arisen in recent years. We were contacted by the mother of baby Conor Whelan in the last number of days asking us to put in a plea to the committee to make sure that the maternity strategy is implemented in this particular area. She strongly believes her baby would be alive today if anomaly scanning was available and that is incredibly sad.

An issue that has arisen in rural maternity hospitals is that midwifes are often trained but cannot be retained. A number of units have trained midwife sonographers who have then left because there are better working conditions abroad, as Professor Kenny, already mentioned. Once they have completed their training, it is more attractive for them to seek employment abroad. Initiatives could be put in place around retaining staff who have been trained. For example, part of the training package could be that they must sign up to remain within the service for a certain number of years, which would at least go some way to addressing that. On the timescale for implementing something like that, it would very much depend on the willingness of the HSE to put funding in that area and training.

A number of members raised issues around mental health and it is an area in which Ireland is far behind compared to other jurisdictions. In the UK, for example, the former Chancellor of the Exchequer, George Osborne, put a £1.2 billion package in place to address perinatal mental health about two years ago. This was on the back of a report commissioned by the Maternal Mental Health Alliance which showed that expenditure of an additional £337 million was needed to bring NHS mental health care to a recommended level. In response, George Osborne committed £1.2 billion to be spent on an expansion of mental health services for children and mothers of new babies. The reason he did that was that we now know that the impact on infant development of undiagnosed perinatal mental health issues is absolutely huge and the cost of that to a country is enormous.

That particular report suggested that there was a cost of £8 billion per year to the UK economy of undiagnosed and untreated perinatal mental health issues. One can see that it is an area well worth spending money on. It is something about which many women regularly come to us. In Ireland, our mental health services as a whole are under-resourced. There are communication issues between maternity services and mental health services and there are issues around data protection and confidentiality. Pre-conception care also plays a part for women who experience perinatal mental ill health. For example, for women who have experienced bipolar disorder, it is vital that pre-conception counselling takes place. Many would be on medications that need to be monitored during pregnancy, etc. I sit on a perinatal mental health group that has been recently set up in University Hospital Galway, and it has been eye-opening for everybody involved. When one has psychiatrists and mental health teams sitting down with maternity services, it is eye-opening for all sides. Very often, women going to maternity services will not necessarily divulge that they are patients of mental health services and, vice versa, when they are seeing their mental health teams, for a significant part of their pregnancy, they may not divulge that they are pregnant. Communication is a vital tool here, and there needs to be a lot more integration with mental health services. As Dr. Boylan said earlier, there are only three part-time perinatal psychiatrists in the country, and they are all based in Dublin, which is, in itself, very telling. There are no perinatal mental health psychologists in Ireland. By contrast, in France every unit has a perinatal mental health psychologist. The lack, or poor standard, of post-natal care in Ireland, both in hospitals and in the community, leads to many women being undiagnosed. For example, we have no screening policy for post-natal or ante-natal depression in this country. As Professor Kenny mentioned, in the UK women would have visits from health professionals, and the Edinburgh post-natal depression scale is used to screen for post-natal depression. It is a separate issue, but most units here are seeing an increase in ante-natal anxiety and post-natal anxiety, as distinct from depression. We are not screening for either. Many women are fearful of disclosing that they are suffering from post-natal depression or ante-natal depression. They are fearful of involvement of child services, a fear which is often unwarranted as most women would be treated very well, but it is a stigma that we need to address. That comes about through education, and women being educated very early on.

Practically everything else I wanted to talk about has been covered. I know cherry-picking was mentioned earlier. We would be particularly concerned about whether all models of care get an equal bite of the cherry, because that is what is best for women. In particular, post-natal care has been the forgotten part of maternity services for a very long time, and it definitely needs to be addressed. In most regions of the country, women are lucky to see a public health nurse once or twice maybe, at most. This has been reduced significantly over the years. When I had my first baby 24 years ago, I saw my public health nurse four or five times. That is now a thing of the past. A post-natal stay in hospital 24 years ago for a normal vaginal delivery was five days, in my case. That was to ensure that the mother was well, that she was emotionally well to go home. Most women are now home in a day if they have a normal vaginal delivery and, for caesarean section mothers, three or four days, maybe. There is very little assessment done as to what care or support a woman has at home.

Many women have emigrated here and, therefore, have very little support at home. Many Irish women live far away from their own families. These are all issues that we are afraid will get less attention when the strategy is implemented. This is particularly true for models of care. We feel that home birth and midwifery-led care should play a large part in the delivery of the service overall, in terms of reducing the pressure on high levels of obstetric-led care. If women with normal low-risk pregnancies are going through the same system, it affords obstetricians less opportunity to spend time with high-risk women.