Dr. Krysia Lynch:

Members have raised many issues. I will address the comments we have just heard before responding to some of the detailed questions asked by Deputies O'Connell and Durkan. On the lactation medications, from the many hundreds, if not thousands, of women I have spoken to in the past 13 years, while the issue is partly one of a lack of understanding among the women in question, it is primarily one of a lack of understanding on the part of the person to whom they go to have medications prescribed. General practitioners will frequently tell women they cannot take an anti-depressant when they are breastfeeding and will prescribe an antibiotic. There are publications on this, of which the most notable are by Hale and pharmacologists working in this whole area, including Wendy Jones. These studies are available to anybody with access to Google. One can look up what types of risks are associated with using what are deemed to be L1, L2, L3 and L4 medications during lactation. Obviously, L4 medications are not to be taken during lactation.

Women who are suffering from post-natal depression are highlighted in particular. Those who are lucky enough to live in Dublin will report that the information they may have received from a perinatal psychiatrist or the hospital they are attending differs from the information they are receiving from their general practitioner. This is an issue in and of itself and probably one which requires training or greater awareness. There is some type of gap in this respect.

I will allude to some of the comments Dr. Boylan made about home birth. The national maternity strategy steering committee heard from many experts in this field, both nationally and internationally, and evaluated all of their evidence. As a result of this evidence, the committee made the recommendation that home birth is a viable option and setting for low risk women. One of the studies that was discussed in detail, the birthplace study, looked at more than 63,000 births in the United Kingdom. The study revealed that for women who are having a second or subsequent child in a straightforward normal pregnancy, home birth was as safe as birth in an alongside birth centre and this is as safe as an independent free-standing birth centre, which, in turn, is as safe as an obstetric unit for such births. The caveat was that for women who are experiencing their first pregnancy, there was a very small but significant increase in perinatal poor outcome with a home birth, but not with an alongside midwifery led unit or a free-standing birth centre. That is the research that we acted upon and to which Dr. Boylan may have been referring.

On the question regarding home birth and breastfeeding, particular groups of women choose home birth and these women will do extensive research in arriving at their decision because this is not an option we offer to women as an obvious choice. When women pronounce themselves pregnant at the general practitioner they are not automatically told they can have a home birth. As such, this an option they must research themselves. Someone who does significant research will find what is best for themselves and their baby, which includes breastfeeding. However, the key issue is the continuity of care that a woman will receive from a small number of midwives or perhaps one midwife whom she will see throughout the pregnancy and with whom she will talk for perhaps one or two hours at every antenatal visit. Home birth visits involve perhaps two or three hours of speaking to somebody antenatally at every antenatal appointment. Unfortunately, women do not get this in hospital, where they will have a five minute or ten minute visit if they are lucky. Given the absence of continuity of care, except in the case of women who choose to go private, a few minutes of every appointment will involve the woman repeating exactly the same explanation as she gave at her previous appointment because the person she will see will not be the same person she saw on the previous visit. In terms of breastfeeding rates for home birth, therefore, I underline that it is the continuity of care that women receive which enables the higher rate.

On mastership, while the strategy recommended a mastership model for all hospitals, it added a caveat. My two colleagues on my right may have assumed that the master would be an obstetrician. However, the strategy referred to the master being a clinician, who would not necessarily be an obstetrician and could potentially be a midwife. The post would be available to either profession and it needs to be acknowledged that it would not necessarily be a particular type of clinician. It could be one of several clinicians.

There are two female masters in the Dublin maternity hospitals and they both like the term "master". The majority of women do not like the term, however, because if there is a master, there must be a few slaves. Nobody wants to be viewed in any way as being in a position where someone else is his or her master or has autonomy over them. While we wholeheartedly agree with the concept of mastership, we have some difficulty with the lexicology.

I will not comment on folic acid, the adverse events and the lack of screening because these issues have been covered. Health promotion is an area that needs to be heavily resourced as it has been subjected to budgetary cuts. This needs to be investigated and examined.

We were asked about public health nurses and midwifery. Until recently, it was necessary to be a midwife or at least have an 18-month diploma of midwifery in addition to nursing to be a public health nurse. This has not been a requirement for five or six years. If there are older public health nurses working in the community, they will have midwifery, whereas younger, more recently trained public health nurses will not have midwifery. That was a decision taken by the profession and one I do not believe has necessarily served well the women who are being taken care of by public health nurses immediately post-partum. Obviously, public health nurses have an extensive remit and it is not exclusively focused on women who have just had babies. However, this is an unfortunate development as far as women are concerned.

We were asked about mothers being separated from their babies and the differences in public and private care in that respect. The ratio of midwives to women they are caring for in a post-partum scenario will be much lower in private care, which means the women will receive more one to one care than they would if they were in a public setting. However, our experience has been that, whereas the public-private divide can be quite marked in other aspects of maternity services, in terms of women separated from babies who are in a neonatal intensive care unit, NICU, being encouraged to express, I do not believe the divide is especially marked in terms of public or private care. All women are encouraged to express if their babies are in a NICU. The variation is between units and not necessarily between private and public.

For example, Limerick general has produced astounding research associated with lack of infection and secondary infections in babies in the NICU because all the babies get breast milk.

A lactation consultation in the National Maternity Hospital has just finished a masters study looking at ensuring that every baby in the NICU received breast milk. One of the issues is Ireland does not have a breast milk bank. There is one in Northern Ireland, which will be in a different jurisdiction following Brexit. This is a random issue that Brexit might affect. I do not know what the effect of that will be. Moving forward, we in the South should have the capacity for milk banks, and not just one, in order that women who genuinely have great difficulty in giving their babies breast milk have another option. Regional milk banks have been suggested. Currently, because of the lack of milk banks in Ireland, there is informal milk sharing among women through a website, Human Milk 4 Human Babies. Women visit that site because they need supplementary breast milk. They do not want to give artificial milk but they are unable to access the milk bank in the North.

I was asked if we have home births, midwifery units and domino births, how we can be sure the babies and mothers will be safe if they are scanned. There are strict criteria for acceptance on to a home birth programme or a midwifery-led unit or a domino service. They include a scan and constant screening antenatally. The NPEC has produced an audit of each home birth for the years, 2012 to 2014. The 2015 audit is due. The audits show that the majority of women who do not get to have home births have been screened out antenatally. They planned a home birth, signed up and fulfilled all the criteria at 12, 13, 14 and 15 weeks but as time went on, did not continue to fulfil the safety criteria. The majority of women are removed from a home birth service antenatally before they go into labour.

I refer to perinatal mental health and mother and baby units. I sit on a specialist perinatal mental health committee that is examining how these issues can be addressed and it will publish a report soon. One of the issues the committee has come up against is the administrative zones for mental health services are different from those for maternity service provision and, therefore, where there is a crossover of two services that need to interleave, there is an issue. For example, Wexford and Waterford hospitals are in the same mental health administrative area but they are in different maternity hospital groups although they are close geographically. That will cause difficulty in determining how care can be allocated and developed. Mother and baby units are needed. Currently, women who suffer from perinatal mental health issues such as depression or extreme conditions such as post-traumatic stress disorder, bipolar disease or psychoses have to be admitted into normal adult mental health facilities that are available in the community. That means they are separated from their babies. Ms Kerans will comment further on that. With regard to the information women with perinatal mental health issues receive- it is not just about breastfeeding - they are reluctant to indicate that they have them because they are frightened that their baby will be taken from them. They are afraid of Tusla getting involved. That is a known factor in the underestimation of the number with perinatal mental health problems.

I am not sure what the Deputy was referring to regarding data protection but we are implementing a new electronic health record. Hopefully, that will be seen to be useful for women. In other countries, for example, Germany, there is what is called the Mutterpass. Everything the woman encounters during her pregnancy journey is inputted into this electronic chip health record, even if she attends different settings or health care professionals. Local community health care provision is also recorded. All that is put on the one card and everything is collated in that way.

Regarding the next steps for implementation, the most important is to have an implementation committee appointed and an implementation plan. My assumption is the strategy forms part of that.

Deputy Durkan asked what are the main areas. He referred to the tragedies we have witnessed. The media are a funny beast. They pick up certain issues and they want to run with them but they are not necessarily the issues or the outcomes that we want highlighted. Being a journalist means highlighting anything that will get your newspaper read and more publicity. We have heard of the deaths of both mothers and babies but what is more important to me in the work I do is the day-to-day tragedies that people feel that they face. These tragedies would never make a media headline because they are not deemed to be that important. There are issues that affect women hour to hour. Professor Kenny referred to a mother not being able to hold her baby when her baby was dying. These tragedies are of no interest to journalists because they will not make the headlines. Women and their families face these tragedies, whether they involve a death. In general, they do not relate to death; they relate to the way they have been treated or what has been said to them or available choices. Women experience such tragedies in every one of Dublin's maternity hospitals, which have a mastership programme. We know because they tell us that every day. While I agree with a clinician being in charge of a hospital, I do not say that only governance issues will stop those day-to-day tragedies. There are issues associated with postnatal physical and emotional care that are important, which we have highlighted. There are issues associated with continuity of care and different care models. Women have little choice in the way they are cared for and who cares for them in Ireland. It is incredible that our country has so little choice for women, especially in rural areas.

A number of the initiatives that have resulted from some of the tragedies, for example, the bereavement standards, have been important. Couples who experienced tragic outcomes with their babies highlighted their issues and the State took them on board. We have fabulous bereavement standards, which, hopefully, will be implemented and audited.