Dr. Margo Wrigley:

I also thank the committee for the invitation to talk about the specialist perinatal mental health service and specifically about its design and national implementation. The next slide aims to put the programme in context. On the numbers side of the slide, we see the number of women likely to develop mental health problems each year. These figures are based on an annual birth rate of approximately 60,000. To give on example, approximately 2,000 women might be expected to develop a severe depressive disorder. The other point to be made is that women may suffer from a whole range of mental health problems.

My colleague, Professor McCarthy, will give members a bit more of a feel for that.

When we started this programme, there were just four whole-time equivalent staff working in the area of perinatal mental health, all based in Dublin. There were three part-time psychiatrists. One was working with a mental health clinical nurse specialist, the second was working with two perinatal mental health midwives and the third was working alone in the Coombe hospital.

It is really important to identify these problems not only because of the impact on the mother, which is substantial, but also because of the impact on the infant, which can be lifelong, causing a range of emotional, behavioural and cognitive problems. Naturally, of course, there is an impact on the wider family. There is a very strong economic argument for providing services. A very reputable study carried out by the London School of Economics showed that for each birth in the UK, there was a cost of £10,000 in terms of perinatal mental health problems. This was for each woman, irrespective of whether she had such a problem. It was found that the cost to remedy the problem would be just £600. In that context, there is an enormously strong economic argument for dealing with the problem.

The seminal event in developing this programme was the publication of the Government's national maternity strategy in 2016. At that time, we had a mental health division within the HSE and considered the strategy. That then national director decided it would be appropriate for us, as the providers of secondary care mental health services, to consider how we might meet the requirements associated with the seven mental health points outlined in the strategy. As Dr. Niazi has already said, we worked on the strategy and it was published at the end of 2017.

The working group was multidisciplinary, as one would expect with any mental health strategy, but, crucially, we had service-user input provided by the Association for Improvements in the Maternity Services - Ireland, AIMSI, through Dr. Krysia Lynch. While we had been asked to look at the specialist perinatal mental health response to women with moderate to severe problems, on foot of the strong advocacy of AIMSI we expanded that to ensure there would also be a response provided to women with mild to moderate problems. We covered those two areas. The aim was to have both responses integrated with the maternity services because it is in those services that pregnant women and women whose babies are to be delivered present.

The next slide is to show members exactly what we have developed. We had two challenges to start off with. One was that there are actually 19 maternity services in Ireland. The second was that the number of births ranged from a high in the Rotunda last year of over 9,000 to a low of 950 in the south Tipperary maternity service. A number of the services have a high number of births, a couple have an intermediate number, and most have about 1,500. Therefore, in order to provide a national service, we recommended the development of the service according to a hub-and-spoke model in line with the maternity networks recommended in the national maternity strategy, which are modelled on the hospital groups. The idea was that the hub hospital maternity service would host the multidisciplinary specialist perinatal mental health team, led by a perinatal psychiatrist. I have listed in the slide where the six services are based. In the spokes, the psychiatry service is provided by liaison psychiatry. We recommended that both elements have perinatal mental health midwives working within the 19 services. The map shows the hub-and-spoke model. In Galway, for instance, the team is based in Galway University Hospital maternity service and it is working with four spokes: Portiuncula, Mayo, Sligo and Letterkenny.

The only point I would like to make on this clinical pathway is that when a woman arrives at a maternity service for the first time for her book-in clinic, she meets a midwife. The midwife asks her not only about her physical health but also about her mental health.

The two specific questions asked are if she has in the past month been feeling low, depressed or down in herself; and if she has in the past month lost interest or pleasure in doing things. If the woman says "Yes", she is asked if this is something she would like help with and can then be referred on to the service. Other questions are also asked about current and past mental health history and family history. Who the woman is seen by depends on the severity of the problem.

The responsibility of the hub team is to provide advice to the spokes - specifically the perinatal mental health midwives and the liaison service - offer second opinions on women attending those spoke services where this is clinically indicated, organise monthly network meetings and organise relevant education for the staff in both hub and spoke services and the maternity service as a whole.

We are almost five years on from the implementation of the programme. I, as clinical lead, and Ms Fiona O'Riordan, as programme manager, were asked by the national director of the mental health division to stay on and oversee the implementation of the programme. We were very fortunate in that, right from the start, there was some funding allocated to implement the model of care. The division allocated €1 million. A further €2 million was allocated by the Minister of State with responsibility for mental health at the time. Subsequently, €1.2 million was allocated to us by the national women and infants health programme. That was specifically for the perinatal mental health midwife posts. Last year we got another €0.6 million from the national women's task force. We have a total of €5.8 million to implement part of the programme. What we worked on in the early days was recruitment, training and induction of new staff. We were very lucky that though we only had four people working in the area, they were all very highly skilled and very supportive of the programme, particularly Professor McCarthy. They were involved in providing induction and people came to visit the services and stayed with them for periods of time. When the first two full-time perinatal psychiatrists were in post in April 2018, we set up a national group. That has expanded to encompass all six hubs and ensures spoke representation and representation from each discipline. For instance, we have Dr. Niamh O'Dwyer from Limerick representing psychology. We developed a data set to capture clinical activity and we have worked on advancing the development of a mother and baby unit.

To give the committee an idea of the staffing that is in place, we now have a full staffing of all the multidisciplinary staff we recommended for each of the hub teams. We have included the administrator in the hub team because they are the first point of contact for women and their families so it is important to have them working with us as part of our team. In addition to the recruitment for the hub teams, we also recruited perinatal mental health midwives for each of the spoke sites, with 13 in total. They are all in place, as well as perinatal mental health midwives for the hub sites. I have listed the sites on the slides.

As to how we were able to implement all of this, we had an implementation mechanism that was put in place by the division. Ms O'Riordan and I have done that. We also had funding allocated because we would have gotten nowhere without funding, to be quite honest. We had the existing highly-trained staff, as I have already mentioned. We were able to work collaboratively with the national women and infants health programme, so that is very much in line with Sláintecare principles of integrated care. A key part of this was developing the perinatal mental health midwife role. That started in the Rotunda but is now available at all 19 sites.

We also have good working relationships with hub and spoke sites and the HSE national recruitment service. We have provided two tranches of bespoke training. We had a link with Maudsley Hospital in London, which was very helpful in that regard, but now have our own very highly trained staff. We have developed a map for all staff who are in contact with women in this period. In a recent development, we now have six full-time higher training posts in perinatal psychiatry which means that we can provide our own psychiatrists who are trained in this specialist area to work with women during the perinatal period.

Moving to the next slide and without wishing to paraphrase a very famous man who was previously in these Houses, we have done a lot but there is a lot more to do. I will mention our key priorities. We are still not happy with the clinic accommodation for the three hub teams provided on HSE sites in Galway, Cork and Limerick. To give the committee an idea of the situation, we have eight clinical staff in Galway. From Monday to Thursday, inclusive, they have just one clinic room for eight staff, which obviously does not compute. On Fridays, they have three rooms. That is a big problem. We have introduced video-enabled care but that does not meet the needs. That is a major issue.

A national mother and baby unit is absolutely key because now, if a woman develops a severe mental health problem, a postpartum psychosis for example, and requires in-patient care in a mental health unit, she has to be separated from her baby. That is very traumatic for the mother and I cannot even begin to describe the effects on the baby, which Dr. Ní Longphuirt has already touched on. The effects are not just immediate. For the infant, they are lifelong and have an impact into adulthood. We would like to develop support from perinatal psychiatrists through the spoke links by providing a ring-fenced perinatal psychiatry session for each spoke link. With the funding we got from the national women and infants health programme, we are going to be able to do that in the Galway spokes. Each of those four spokes will have a ring-fenced session. The perinatal psychiatrist will be linked in to the liaison service, the perinatal mental health midwife, to provide supervision and advice to the psychiatrist, where necessary. The psychiatrist will also provide a virtual second opinion for women attending the spoke sites.

The next slide brings us back to what this programme is all about, women and their infants. We would like women to be aware that mental health problems are common during this period. They affect up to one in five women during pregnancy or in the year after delivery. They are not the women's fault and are not nothing to be ashamed of. We would like women to be compassionate towards themselves and to seek help. We have tried to reform the system but it is only part of the system. As Dr. Ní Longphuirt said, there are other parts that need to be developed, for example, primary care psychology. However, we have tried to reform the system to meet the needs of women and their infants and to ensure that the services we provide are recovery-focused, imbued with hope, accessible to women and provided by skilled staff. We hope the outcome will be an enhancement of resilience in women and the development of resilience in infants. The mother-infant bond is the focus of the interventions we provide within the specialist perinatal mental health services. That, in itself, will be of lifelong benefit for infants into childhood and, eventually, adulthood.

The picture at the top of this slide shows a World Mental Health Day event the Limerick hub team organised in Castletroy Park Hotel last Monday. Approximately 70 women who attend the service came along and 23 or so brought their babies along. They had a great day. That is just to give the committee an idea of who we are talking about.

Some of them prioritised attending on the day when they had their appointments with Dr. Mas Mahady Mohamad, who is the consultant perinatal psychiatrist in Limerick.

The final gives the committee the link into the programme if the members are interested in having a closer look at it. I thank the committee.