Frances Black (Independent)
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The purpose of the meeting is to discuss issues relating to perinatal mental health. To enable the sub-committee to consider this matter, I am very pleased to welcome, from the Psychological Society of Ireland, PSI, Dr. Eithne Ní Longphuirt, senior clinical psychologist and chair of the PSI's special interest group in perinatal and infant mental health, and Dr. Jillian Doyle, senior clinical psychologist and member of the PSI’s special interest group in perinatal and infant mental health; from the HSE, Dr. Amir Niazi, national clinical adviser and group lead for mental health, and Dr. Margo Wrigley, national clinical lead, specialist perinatal mental health programme; and from the National Maternity Hospital, Professor Anthony McCarthy, consultant psychiatrist and perinatal mental health expert. The witnesses are all most welcome to the meeting. All those present in the committee room are asked to exercise personal responsibility to protect themselves and others from the risk of contracting Covid-19.

Witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable, or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks.

Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that any such direction be complied with.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official, either by name or in such a way as to make him or her identifiable. Members are also reminded of the constitutional requirement that they must be physically present within the confines of the Leinster House complex in order to participate in public meetings. I will not permit them to participate where they are not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting. In this regard, I ask any members partaking via MS Teams to confirm that they are on the grounds of Leinster House campus prior to making a contribution.

To commence our discussion, I invite Dr. Eithne Ní Longphuirt to make opening remarks on behalf of the Psychological Society of Ireland.

Dr. Eithne N? Longphuirt:

On behalf of the Psychological Society of Ireland, I thank the Chairperson and members for the opportunity to address the sub-committee. I am Chair of the Psychological Society of Ireland’s special interest group in perinatal and infant mental health, SIGPIMH. I am accompanied by my colleague, Dr. Jillian Doyle, and she is a committee member of the special interest group.

Perinatal services are where the earliest interventions begin for mothers, care givers, and infants. These are the interventions that set the foundation for the mother-child relationship and, indeed, provide the blueprint for much of a child’s later emotional development. We know that investing early and smartly by supporting parents and family systems is likely one of the more cost-effective ways to promote mental health.

The focus on mothers, infants and relationships in the context of the broader family. Today, we will advocate for a broadening of the model of perinatal health in the following ways: to invite the infant into the perinatal services and the services into the world of the infant; to include those who have been largely excluded; to provide a continuum of care between perinatal and community services; and enable perinatal services to become trauma informed.

As the perinatal model of care takes root, psychologists increasingly recognise the need to provide services that cater to the needs of the mother-child dyad. Perinatal teams are at capacity in meeting the mental health needs of pregnant and postpartum people. We know that the first 1,000 days are the most significant in a child’s development and, therefore, we believe that each of the perinatal teams would benefit from an infant mental health practitioner. We also strongly advocate for the provision of mother and baby units that cater comprehensively for the needs of the mother, child and family.

We must move towards a model of combined care that alleviates the mental health burden on parents and encourages the global development of children. The current iteration of the perinatal services is not equipped to carry out work with babies. Services are in portacabins and in shared office spaces. We need to expand perinatal services so that both mothers and babies are supported, and clinicians have the appropriate tools to do the therapeutic work.

To date, no service has been developed for partners in the perinatal period. Evidence suggests an unmet treatment need for paternal depression and anxiety. Lack of support from the partner is one of the strongest predictors of postnatal depression in women. This is a service gap.

Teenagers are at high risk of developing perinatal mental health disorders. Due to their age this cohort cannot access perinatal services thus denying them access to timely and appropriate care. We advocate for the provision of psychological care to this cohort and believe that a working group could be formed to explore how best to provide this care.

Unsurprisingly, parents of premature infants in the neonatal intensive care unit, or NICU, are at high risk for depression, anxiety and acute traumatic stress with negative implications for parenting and infant development. Researchers recommend ongoing assessment of the perinatal mental health needs of parents as part of the network of services available in NICU. Adequate staff resourcing of the health and social care professionals team, as highlighted in the neonatal model of care, would help actualise perinatal and infant mental health across NICUs and paediatric intensive care units or PICUs in Ireland.

Primary care psychology services are ideally placed to meet the unique experiences of the perinatal period. The perinatal model of care advocates for primary care psychologists to prioritise pregnant women. Prioritisation has been impacted by restrictions on public health nurse screenings, which limits referrals, and by long waiting lists. We believe that investment in primary care psychology will ensure a continuity of care for women and families.

Finally, best practice tells us that care offered to women should be trauma informed. Trauma-informed care prioritises safety, choice, decision-making and control. Healthcare professionals also need to be supported via the provision of adequate staff, regular training and supervision about how to communicate with and care for women.

The Psychological Society of Ireland, PSI, recognises that operating from this value base will require significant systemic change. However, we believe that the benefits to women, infants, partners, healthcare staff and society will ultimately greatly outweigh the cost of change.

According to the eminent psychologist John Bowlby, “If a community values its children, it must cherish their parents”. In the PSI and our special interest group, we strongly believe that perinatal and infant mental health services offer a unique opportunity to cherish both parents and children in Ireland. We urge you, the leaders of our country, to invite in the infant, the mother and the family. As a State, we have birthed these perinatal services; now it is time to parent them and help them to reach their full potential.

Dr. Amir Niazi:

I thank the Chairperson and members of the committee very much for the invitation to talk about the issues relating to perinatal mental health. My colleague, Dr. Margo Wrigley, the national lead for the specialist perinatal mental health programme, and I are here on behalf of the HSE.

In my role as national clinical adviser and group lead in mental health, I work with national leads and programme managers on the design and implementation of the clinical programmes in mental health. The specialist perinatal mental health programme is one of these. Other programmes we look after include programmes on: self-harm in emergency departments; early intervention in psychosis; eating disorders in adults and children; attention deficit hyperactivity disorder, ADHD, in adults; and dual diagnosis, which is where addiction issues and mental health issues present together. We also support service improvement programmes such as those on mental health services for those with intellectual disability and older persons.

All of these clinical programmes and service improvements have certain things in common. One is that they address unmet clinical need. Most of the mental health services are delivered by primary and secondary care services but there are certain cohorts of patients that need bespoke specialised services. Clinical programmes and service improvement programmes plug that gap. We have an overarching aim of standardising quality, evidence-based practice across mental health services. This means that the service provided in Dublin should be the same as that provided in Cork, in Donegal or anywhere else in the country. We try to step in early. Early intervention is key. Community orientation is one of our focuses. Rather than bringing people into acute units, we try to manage them in the community as much as possible. Most of our models of care and initiatives involve work with training bodies and voluntary organisations. We take a holistic approach with all of these programmes.

As I mentioned, most mental health services are delivered by primary and secondary care services. Only those patients who require a bespoke specialist response to ensure their needs are met promptly by skilled mental health professionals are referred to these clinical programmes. The specialist perinatal mental health programme specifically meets the mental health needs of women during pregnancy and up to a year post delivery. This programme was launched in 2017 and implementation started in 2018. Dr. Wrigley will brief the committee on the services now available for women. We have prepared a few slides that give an overview of the service. We are happy to take any questions at the end to help members understand our programme.

Dr. Margo Wrigley:

Is it possible to show the slides? If not, I can-----

Frances Black (Independent)
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Are we able to show the slides? Yes. Fantastic.

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.

Frances Black (Independent)
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I thank Dr. Wrigley and Dr. Niazi. I now invite Professor Anthony McCarthy to make his opening remarks on behalf of the National Maternity Hospital.

Professor Anthony McCarthy:

I thank the Chairman. I have been a consultant psychiatrist in perinatal psychiatry at the National Maternity Hospital for more than 26 years. During this time, I have seen and been responsible for the care of more than 15,000 women, including those in health difficulties in pregnancy or in the postpartum period. I previously addressed Oireachtas committees on the subject of perinatal mental health. I addressed the citizens' assembly on the protection on life in pregnancy legislation. I am an associate professor of psychiatry at UCD. I am also an expert psychiatric assessor for the confidential inquiries into maternal deaths in Great Britain and Ireland. I thank the committee for inviting all of us to address the members today. Trying to fit my contribution into five minutes will be very difficult. I completely agree with everything that has been said by the previous contributors. I will try not to repeat was has already been stated.

The specialist perinatal mental health services are a vitally important component of our mental health services. Why are they so important and necessary? First, pregnancy, birth and the demands of new motherhood can be seriously challenging for any woman's mental health. Second, a mother's mental health difficulties can have very significant negative impacts on obstetric outcomes and on the baby. It works in both ways.

I will outline the challenges of pregnancy for women's mental health. A mother is 19 times more likely to be admitted to a psychiatric hospital in the first six weeks after the birth of a baby than in any other six-week period in her whole life. It is a particular window, but it does not stop there. Post-natal depression affects 11% of all new mothers - which in one in nine - and is the commonest complication of pregnancy. It is more common than infections, trauma or bleeding. A psychotic illness post-delivery occurs in one in 500 mothers. Although the image of mothers in pregnancy is often of women glowing and contented, in reality pregnancy is frequently an extremely challenging time for women's mental health. Normal pregnancy can be very physically and emotionally demanding. Any women in the room who have had babies will know all of this. While having a child is joyful and meaningful too, many women may have to deal with miscarriage, still birth, haemorrhage or pre-eclampsia, not to mention complicated deliveries, traumatic deliveries, hormone changes, the demands of breast feeding and other complications and demands. That is the physical side.

The psychological and social challenges of pregnancy are considerable for so many. There are unplanned pregnancies, unwanted pregnancies, or the discovery of major abnormalities. There are previous difficult pregnancy experiences and the woman is pregnant again or there have been pregnancy losses before. There may be complications in relationships due to pregnancy or the massively significant increase in domestic violence associated with pregnancy: men are much more likely to be violent or have affairs when their partners are pregnant. Previous psychological or psychiatric issues are frequently exacerbated by pregnancy, and very often new and seriously challenging issues, as listed above, present for the first time. Previous mental health difficulties, such as anxiety, depression, bipolar illness, and post-traumatic stress disorder do not disappear in pregnancy and are often complicated by it and frequently worsen after it unless addressed and appropriately treated. All of these pose considerable risks to the well-being and sometimes the safety of the mother, her baby, and her whole family.

The other side of it is that mental health difficulties affect pregnancy outcomes. Mothers with significant mental health disorders frequently present differently to antenatal clinics, post-natal clinics and emergency rooms. For example, those with depression, psychosis, post-traumatic stress disorder, etc., are less likely to attend for appointments or scans and will therefore have issues missed. Others with major anxiety disorders may present over-regularly and obsessively and may exhibit risky behaviours as a result. I will list the latter afterwards.

Those with major mental health issues can struggle with adherence to advice regarding medication, whether it is for medical conditions such as diabetes in pregnancy, eating disorders in pregnancy, or hypertension in pregnancy, and they are less likely to take vaccines or psychotropic medication for their mental health disorders. Similarly, advice around diet, baby care, and safety are sometimes more likely to be ignored, misunderstood or misinterpreted.

Women with mental health difficulties are also more likely to be victims of domestic violence and abuse.

There are increased rates of termination of pregnancy among women with mental health issues. They are also more likely to have premature deliveries and instrumental deliveries, such as deliveries requiring forceps. Caesarean sections and traumatic births are more likely. It works in both ways: traumatic births can affect women's mental health and women with mental health difficulties are more likely to have traumatic births. Again, it is circular and we must always address both sides.

At-risk behaviours are more common in women with mental health difficulties. I refer to increased rates of smoking, drinking and drug abuse during pregnancy, possibly resulting in withdrawal syndromes among babies or foetal alcohol syndrome. Women with eating disorders may have a very poor diet, be vomiting or use purgatives. Those with anxiety may physically over-check their babies. Women who are highly anxious about their babies not moving may press on their stomachs to check for movement, maybe at 3 a.m., 4 a.m. and 5 a.m. After a baby is born, an anxious mother may wake it up constantly to check on it because she fears it will suffer a cot death. Such mothers cannot deal with their anxiety or obsessional worries. All of these issues are associated not just with obstetric complications but also with subsequent developmental and attachment issues, to which my psychology colleagues have been referring.

There are also the serious mental health issues leading to suicide and infanticide. Suicide is the second most common cause of maternal death in the country, although it is still uncommon. Despite many of the advances in obstetric care, it is still a huge issue. Infanticide, while fortunately rare, is always a tragedy, and the rate is probably underestimated.

The other major mental illnesses that can present at this difficult, key time, including psychosis and depression, have all been shown on the slides. Frequently, these can have lifelong effects, not just on the mother's mental health but also on that of the infants. There can also be lifelong effects on the mother's relationship, her relationship with her baby and sometimes her relationship with other children. She may never quite recover.

What are the functions of the perinatal mental service? Dr. Wrigley has listed these already but I wish to flesh the subject out a little. One function is to assess and advise women referred to the specialist mental health teams with mental health difficulties through pregnancy and the first year after birth. Another function is to assess, diagnose and treat effectively those mothers with moderate to severe mental health problems through pregnancy and the first year after birth, and also to carry out expert risk assessments because the risks are huge.

Treatments may include psychological interventions, social interventions, psycho-education, parenting supports and skills training. Also included are safe prescribing and advice on the safe prescribing of medication in pregnancy and after birth. We do not stop treating people with major mental illnesses with their medication during pregnancy or if they are breast-feeding because the balance of risks is huge in such circumstances. We must proceed safely and be able to give expert advice to mothers and psychiatry services throughout the country, certainly those in our spoke hospitals.

Treatments also include referring for psychiatric admission those mothers who are most at risk and in need of inpatient treatment. As mentioned, the absence of a mother and baby unit for mothers who require admission is the single biggest deficit in our services. We also make referrals to key community services, whether these involve primary care psychology, services in the voluntary sector, Barnardos, mothering skills supports and supports for mothers in the community. We have to be experts. Our social work team is very good at knowing who to refer to outside the hospital.

Assessment of risk also includes assessment of the mother–infant interaction. That has been listed. The team also gives pre-conceptual advice to those mothers with serious mental illness who are considering pregnancy. That may be advice on mediation, or it might be advice for those who have had a traumatic experience or eating disorder. We also provide specialist assessment and advice as per the requirements under the Termination of Pregnancy Act 2018.

I hope the importance of these issues is understood and appreciated. We certainly understand and appreciate them. The development of the specialist teams and services has represented a considerable advance in care. We are so grateful to the HSE and the Department of Health for supporting all that. Obviously, we need a mother and baby unit and would like to develop more support for smaller maternity units. Obviously, we would also like to develop all the services my psychology colleagues referred to, including supports for infants, fathers and families, and to keep growing them. The need is great. The perinatal period is vital. If it starts off well between mothers and babies, and families and babies, and if babies are securely attached at the beginning and their mothers are well, it is such an investment in the lifelong well-being of the children, their families and our society.

Frances Black (Independent)
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I thank the witnesses for their contributions. It is really powerful to hear the passion they have when speaking about this issue. I now call Deputy Hourigan of the Green Party.

Professor Anthony McCarthy:

As regards eating disorders, as I have described in the case of mental health services in a hospital like Holles Street, we have dieticians. With regard to poverty, there are medical social workers.

Professor Anthony McCarthy:

In the hospital, there is no particular time at which this might happen. People can be referred at five weeks into their pregnancy. Some women who come to the antenatal clinic are asked some woolly questions, which may be an opportunity to raise such issues. Their weight will be taken. Many women with eating disorders have excessive vomiting during pregnancy. Unfortunately, vomiting is a very normal part of pregnancy for lots of women and they often have different patterns of vomiting. When somebody presents with vomiting, people are thinking about weight issues. It sometimes depends on the woman coming forth with the issue and, very often, women with eating disorders have recovered to become pregnant. Many will have recovered to a certain extent, which is how they are able to get pregnant. Those with severe anorexia cannot get pregnant because ovarian function switches off.

For many, there is an opportunity for such issues to be raised and they start to worry about that. They may admit they are taking laxatives. They might begin to talk about it or sometimes we or the dieticians pick it up. We cannot say we always pick it up but we often do. The women are then referred to us. We have a number of patients we are seeing who are also, for instance, seeing eating disorder teams elsewhere. It comes up in all sorts of different ways. The Deputy raised a question as to whether there is a direct pathway for that. The system certainly could be improved but the issues involved present the same difficulties as with every issue. The Deputy mentioned a lot in her contribution. As she was describing all the different issues, whether disability, poverty or eating disorders, it came to my mind that we are constantly dealing with the tapestry of everybody's life.

Pregnancy brings up everything. It is a key moment when one's personal, body and relationship history and personal, mental health, physical and social difficulties all come together and coalesce. It is up to us as a service to be as good as we can at picking that up and then channelling the person towards medical social workers if it is a poverty or housing issue or towards the dieticians, whatever it might be, with all of us working together, I hope.

Dr. Margo Wrigley:

It would be useful, perhaps, to say that the whole thrust of the services is to identify problems early on so that women do not reach the threshold where they might require admission. The fact we have the services in place in 19 sites means there is earlier identification of problems so they do not escalate to being more severe.

Dr. Eithne N? Longphuirt:

Absolutely. At the Psychological Society of Ireland, we are really concerned about public health nurse, PHN, universal screenings and the reduction in those. For the perinatal teams and in particular for primary care psychology, public health nurses are the main source of referrals. They are such a valuable part of this system, and to think that we might miss some of those women-----

Dr. Eithne N? Longphuirt:

We are missing them. It is absolutely a tragedy.

Dr. Eithne N? Longphuirt:

Ideally, if I had a magic wand, at least one a week.

Dr. Eithne N? Longphuirt:

At least one a week. That would not necessarily have to be by a public health nurse. If there is a vulnerable family, it could be another practitioner or someone trained in attachment and relationship issues.

Dr. Margo Wrigley:

As Dr. Ní Longphuirt said, public health nurses are absolutely key. One of the things we did do through the programme last year was work with one of public health nursing units to develop guidelines on how public health nurses, like midwives in the maternity services, would routinely ask women about their mental health when they see them for the routine visits. There are not enough visits, as the Deputy said, but they would ask about their mental health and it is important-----

Dr. Margo Wrigley:

No. That is it. There is a way of asking questions that encourages women to come forth. All of us who work in this area are very conscious of the fact there are groups of women who are afraid to say too much in case the baby is removed from them.

Questions can be asked in a particular way to engage with the woman to try to get that information. The public health nurses need to know how to elicit the information, but equally if they elicit information they are concerned about, what they should do about it. That sort of information is provided in the guideline. That only started last year and, as I said, we have done so much but there is more to do.

Dr. Margo Wrigley:

That only started last year.

Dr. Margo Wrigley:

This is something we developed and the public health nursing development unit came to us and asked for our help in framing how the question should be asked and what the pathway is. A few of the psychiatrists and the perinatal mental health midwives were involved in working out a guideline with the development unit in public health nursing. It is a start. As I said, there is more to do.

Dr. Margo Wrigley:

Yes, it is being done through the public health nursing development unit.

Dr. Margo Wrigley:

I cannot tell the Deputy that at the moment.

Dr. Margo Wrigley:

The aim is that a national guideline would be used and it would be followed up. We are working on the next stage which is to develop some educational videos so the public health nurses can see how the questions are asked. As the Deputy can appreciate, these are not always the easiest questions to ask and they have to be framed in a way that does not terrify women. We want them to answer.

Dr. Eithne N? Longphuirt:

As regards the Deputy's question on disability, like all services the joined-up nature of services has an impact on whether people are referred. We are all aware our disability services are understaffed and it depends on the service and the team whether it has the space, training or opportunity to pick up on parental wellbeing. Sometimes the disability services look to primary care psychology to pick up that piece. Primary care psychology may receive a referral to support parents who have come into the disability service with a child who is seriously unwell and has significant disabilities and to help them through that. It depends on the teams, the relationship between primary care psychology and disability teams and sometimes the disability team will feel it has the resources to do that, but less and less often. However, no formal way or path to support those parents exists. We really depend on local teams and relationships to provide that support.

Professor Anthony McCarthy:

Student public health nurses are now spending some time with our team as part of their training which is helpful. Many mental health and other issues have been hidden for so long and the effect of the opening up of the services, but also a change in society, is that we are getting more referrals. Our issue is people are hiding things less than before. People are much more open about coming forward. It is not universal, but while the number of births in our hospital decreased from 9,600 three years ago to 8,500 this year, our referrals to the mental health service in the hospital increased from 950 three years ago to 1,340 so far this year.

Dr. Margo Wrigley:

That has had a huge impact across the services because the women could not have their partners accompany them and so on.

Dr. Margo Wrigley:

This was Covid-19 specifically. It was also after the baby was delivered. Their closest support, which might have been a mother, may have lived more than 2 km away. What we found was, and Professor McCarthy can qualify this if he wishes, that there was a huge number of women who found themselves in big trouble during Covid-19 because of this perceived and actual isolation and who ran into problems with depression and anxiety. For our part, there was obviously an impact on the services because of Covid-19 and how you could see women. We were very lucky that our programme manager was asked to lend some support to rolling out video-enabled care during Covid-19 and the early introducers of that in the mental health services were the perinatal mental health services. We were able to see some women face-to-face where necessary but video-enabled care was provided as well.

Dr. Margo Wrigley:

Sorry?

Dr. Margo Wrigley:

I could not give Deputy Hourigan any information on that at all. Does Professor McCarthy wish to say anything about Covid-19?

Professor Anthony McCarthy:

That is an obstetric issue rather than a mental health issue.

Professor Anthony McCarthy:

The commonest phrase I use in my work when I am seeing people is to say that I am supposed to be an expert on the biological, psychological, social, spiritual and existential issues that may come up but that the woman I am seeing has to be the expert on herself as much as she can be and that we can try to work it out together. We do not take a view on the safety or not of home births. We certainly see women who have traumatic birth experiences, and we are always happy to see them. Sometimes that will be because of their image of what that birth would be before it, whether a home birth or a natural delivery, and imagining natural as safe rather than summer and winter, natural as beautiful cuddly bunnies rather than rats and tarantulas and natural as doing pregnancy yoga and thinking it is all going to go perfectly well rather than trauma, third degree tears, bleeding and barely living through it. We see women who have had experiences that subjectively and often objectively have been very traumatic, whatever the circumstances. We are not in a position to advise. Sometimes we see women and will recommend to obstetric colleagues on next deliveries. However, we have no role in advising in advance our obstetric colleagues on issues that we have no expertise in but we will always refer to the mental health side.

Dr. Jillian Doyle:

I suppose in talking about control, it is so important that we give women as much control and empower them as much as we can whatever sort of birth they will move towards. Oftentimes if I am talking to a woman about the kind of birth she wants to have, we try to explore why she wants that type of birth. Often a women will go in wanting one type of birth and will end up having a very different sort of experience. It is to try to explore how she feels in control, how we can help her to have the best experience she can have and be as supportive as possible in doing that and how we can help staff guide her through that. There is a really important piece around helping staff move towards trauma-informed care and making sure women understand what is happening, making sure women can give consent and that it is not rushed and making sure there is time and support and that afterwards there is time to reflect on what happened and to integrate it.

Mark Ward (Dublin Mid West, Sinn Fein)
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We could hear the passion and the love the witnesses have for their jobs and I thank them. Any criticism I have is what they have highlighted in relation to what is missing. One can see that the perinatal service is almost there.

With a bit of tweaking, political will and more resources, we could be world leaders in this area. The in-patient facility, the mother and baby unit that was mentioned, is the missing piece.

I will focus on the bricks and mortar of that and see where we are in that process. I was doing some research and I came across comments attributed to Dr. Niazi in April saying the development of the perinatal unit is definitely not in the HSE plan for 2022. He said that the main obstacle standing in the way of progressing the plans was choosing between one of two sites in St. Vincent's Hospital in Dublin. What is happening with that at the moment? That is my first question.

Dr. Amir Niazi:

I wish to acknowledge the Deputy's interest in mental health. I have seen his parliamentary questions because I answer them.

Mark Ward (Dublin Mid West, Sinn Fein)
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I thank Dr. Niazi for answering all of the questions. He probably sees a question coming in from me and thinks " here he is again". We sometimes get bland answers from the HSE, but in fairness the answers I receive from Dr. Niazi and his statements in the media are always honest and transparent. I appreciate that.

Dr. Amir Niazi:

As a member of the HSE, the perinatal mental health programme is one of our success stories. No unit of the HSE would come to the committee and say it does not have a recruitment issue. There are challenges everywhere, but due to the hard work of Dr. Wrigley and the team, every person required for the programme has been recruited and is providing services on the ground. I also want to acknowledge the hard work my team has done.

All options are being looked at for the mother and baby unit. For example, when the Minister of State, Deputy Butler visited The Coombe earlier this year, she was told a unit was being closed and she asked us whether we wanted to develop the mother and baby unit there. The problem was that a mother and baby unit, which is a national unit, has specific requirements. It must be on a site where mental health doctors are on duty 27-7; near an approved centre; and where maternity services are available on the ground. Services for mother and baby must both be available on the ground, so we thanked her but told her it was not ideal or not where we want it to be. Options have been looked at. St. Vincent's University Hospital, Elm Park is a site we have recommended as it has an acute mental health unit, maternity services and all of that. The challenge with that site is there are two options. One is to build on a third floor site along with an eating disorder unit in that facility. The second option is to build it on a green field site in the unit and now people are discussing the possibility of putting the new maternity hospital on the same site.

We are between those, but we are engaging with the estates department in the HSE to see what will fulfil our needs because this is a once-off opportunity and we want ensure we can stand over what we develop and say this is delivering exactly what we are looking for.

Mark Ward (Dublin Mid West, Sinn Fein)
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Dr. Niazi raised the issue of the two sites in April 2022. It is now October, which is six months later and the issue seems to be ongoing. I am concerned it could go on indefinitely. Dr. Niazi mentioned the third floor site and a green field site. Is there a preference? Can we as legislators do anything to apply pressure and get that moving? That is what I am interested in.

Dr. Margo Wrigley:

As Dr. Niazi said, we have made progress and in the past couple of years we have had a sub-committee involving the staff of the programme, the CHO6 mental health services, which are the local mental health services, and St. Vincent's Hospital. Professor McCarthy from the National Maternity Hospital is in that group also. We have an agreed business case and that includes a description of how the unit should be structured. For instance as it is the mother and baby unit, a nursery is needed as well as the single en suite rooms. Bigger bedrooms are needed for the women as they need to accommodate a cot. Staff are required who will look after babies.

All of that is agreed, but the nub point is to get the unit prioritised so that it becomes a bit like the national paediatric hospital - not totally, I hasten to add. It needs to be a priority outside the HSE, a Government priority, that we have a national mother and baby unit to stop what is happening at the moment, which is mothers being admitted without their babies. If it was prioritised at Government level, it would make a huge difference to our progress. As Dr. Niazi said, within the campus of St. Vincent's University Hospital, we have the option of a third-floor extension. That is not going to work, to be honest.

Mark Ward (Dublin Mid West, Sinn Fein)
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That is the question I was going to ask.

Dr. Margo Wrigley:

The hospital has other problems with its acute mental health unit, so it looks like it is going to be a new-build for the working age adult, the older adult unit and the two specialist units, namely, the mother and baby unit and the national eating disorder unit for adults. It will be a new-build. The land is available on the St. Vincent's University Hospital campus. From our point of view, with the mother and baby unit, the absolute priority is that it must be part of, but distinct from, an acute mental health unit. These are the most unwell mothers in the country at any one time and they have to have mental health expertise. That is our priority. The support of the sub-committee for the development of a national mother and baby unit would be a huge support to us. I thank the Deputy for his interest.

Mark Ward (Dublin Mid West, Sinn Fein)
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A decision has not yet been made between the two sites. Dr. Wrigley has identified two sites and-----

Dr. Margo Wrigley:

On the visit the Minister made to the other site, the Master of the Rotunda Hospital made a very kind offer but it was a diversion because the site did not fulfil the requirements that are essential to provide safe care for babies as well as safe and expert care for their mothers.

Mark Ward (Dublin Mid West, Sinn Fein)
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While there are 20 perinatal units like this in Britain, there are none, according to Dr. Wrigley, in the North of Ireland. As such, there is currently no mother and baby unit on the whole island of Ireland.

Dr. Margo Wrigley:

No, not in the whole of Ireland.

Mark Ward (Dublin Mid West, Sinn Fein)
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The North is probably at the same stage as the HSE is in trying to get a unit here and is moving forward slowly. Has there been collaboration between North and South to see if there is any work that can be done together?

Dr. Margo Wrigley:

Yes, there has.

Mark Ward (Dublin Mid West, Sinn Fein)
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Health does not appreciate borders; it goes across borders.

Dr. Margo Wrigley:

We have had a couple of phone meetings this year. We had some early on when Northern Ireland was developing its service model. This year, we have had a couple of meetings to look at what we might do in a whole-island context, with a view to perhaps looking for funding for the whole island and any other funding we can get, to be quite honest with the Deputy. We were looking specifically at how we might work together in terms of having the same operations, but also whether there would be synergies. I am thinking in particular of women in County Donegal, for instance, who may need inpatient care having access to a unit in Northern Ireland if it suited them. They could be given the choice. That sort of provision might be of huge advantage. There are already models in operation such as children's cardiac surgery with children from the North coming to Our Lady's Children's Hospital, Crumlin, to have those interventions. There is no reason we could not look at it in terms of providing care for mothers.

Mark Ward (Dublin Mid West, Sinn Fein)
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That is very interesting. Dr. Wrigley touched briefly in the slides on the accommodation issues in the hubs in hospitals in Cork, Limerick and Galway. Will she outline what is available in each? Are enough clinical space and staff available to deliver a top-class perinatal service? What is missing? What can we do in that regard?

Dr. Margo Wrigley:

For me, working in the HSE, it was a bit disappointing that the three voluntary hospitals in Dublin sort of set to and provided accommodation. They are tight for space, as my colleague from the Rotunda knows. Because we have been so efficient in recruiting staff, they are tight for space and could do with more. The situation is as I outlined. Does the Deputy want me to go through what is in Galway?

Mark Ward (Dublin Mid West, Sinn Fein)
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Yes.

Dr. Margo Wrigley:

I could go through what is available.

Mark Ward (Dublin Mid West, Sinn Fein)
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And what gaps are there and what needs to be improved.

Dr. Margo Wrigley:

We have eight clinical staff working across all the disciplines. They are available every day to see women who are pregnant or who have delivered babies and who have mental health problems. The problem in Galway is that there only one clinical room available Monday to Friday on-site. Women are obviously seen on a one-to-one basis. There is only one member of staff who can use that room and there are seven who cannot. They are trying to see women through video-enabled care, which is good in some situations but not good as being the only was you can see women. On Fridays, there are three rooms available.

The situation in Cork is that they have a base for the team and that includes three kiosks for private video-enabled care. In terms of the clinic space, because there are a higher number of deliveries in Cork, they have nine clinical staff. They have access to one room between Mondays and Thursdays, inclusive, and two on Fridays. We have worked very closely with Limerick. They have access to one room on-site Monday to Friday. The consultant there does a joint clinic with one of the obstetricians for women who have complex physical and mental health issues. It is a lovely clinic to have up and running. However, there is only one room on-site in the maternity hospital. They have hired rooms off-site in order to provide space. From our point of view, it is good that at least they can see the women and it is within walking distance of the maternity hospital. If you are a woman-----

Mark Ward (Dublin Mid West, Sinn Fein)
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Yes.

Dr. Margo Wrigley:

-----and you are going to your midwife and then you have to walk to a different place for your mental health service, it is not good. Our whole ethos was to reduce the stigma of having a mental health problem. So one is coming to Limerick for maternity care. If one has a physical problem and a mental health problem, it should be dealt with on-site.

Mark Ward (Dublin Mid West, Sinn Fein)
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That parity-----.

Dr. Margo Wrigley:

Parity of esteem reduces the stigma, so we do not like the off-site solution.

Mark Ward (Dublin Mid West, Sinn Fein)
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Yes.

Dr. Margo Wrigley:

At least an effort is being made. In the context of what we have suggested could be done on each of those three sites, we hope that it will be taken on board. It is really the Rotunda solution, which is modular units that could be developed very quickly on those sites-----

Mark Ward (Dublin Mid West, Sinn Fein)
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Okay.

Dr. Margo Wrigley:

-----in order to provide an on-site response for women who have mental health problems during pregnancy and post delivery.

Mark Ward (Dublin Mid West, Sinn Fein)
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And, again, in the context of bricks and mortar-----

Dr. Margo Wrigley:

Bricks and mortar.

Mark Ward (Dublin Mid West, Sinn Fein)
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-----where is that in the planning? Has that progressed or is that just a request at the moment?

Dr. Margo Wrigley:

We are working on that. Does Dr. Niazi wish to say something?

Dr. Amir Niazi:

If this was part of the mental health service, we would have better control over it. Because these sites are located on the campuses of acute hospitals, we have to work with those hospitals. As my colleague said, the challenge is that if they offer us a building in an industrial park or somewhere outside, it does not fulfil the needs of what we want to provide. They have to be on-site where the action is happening. The maternity clinic is on-site. The challenge I have seen - not in my current role but in the previous one - is that HSE estates wants to explore all other options before opting for those kind of modular buildings. Those involved want to have proper buildings looked at. If we wait for that, it will be a long time for anything to happen. We are working with acute hospitals to see if modular buildings, such as those used in voluntary hospitals in Dublin, could be looked at.

My colleague has gone to those hospitals and even taken photographs to support our claim that on this green site we could have a modular building that provide supports and service. We are trying to work with acute hospitals and see how we can work together to deliver that service.

Mark Ward (Dublin Mid West, Sinn Fein)
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Technology has moved on 100% in respect of modular builds. A school in my area is a modular build. It is a state-of-the-art building and is not like the old prefabs that people had years ago. These are state-of-the-art places using modern technology. Modular builds should be an option moving forward and they would not have the same stigma as in the past. In here we usually ask for ways to get around recruitment and retention problems but there seems to be an efficiency in the way that the HSE recruits and retain staff in this area. Please elaborate as the model might work across the rest of the HSE.

Professor Anthony McCarthy:

We must congratulate Dr. Wrigley.

Dr. Margo Wrigley:

It is a lovely area to work in because one can do so much to help people and we have no problems recruiting staff. We started with just four whole-time equivalents and we now have 74 staff in place. With the passage of time, staff leave and we are able to fill posts as well. The person to explain this is my colleague, Ms Fiona O'Riordan, but she is not here. The voluntary hospitals do their own recruitment so we cannot take any credit for that. Ms O'Riordan is a master at working with the national recruitment service to recruit staff. We have been able to develop bespoke competitions say, for instance, for mental health nurses, psychology, occupational therapy and social work. We have developed those panels. The staff then know that they are not applying for one massive situation where any job can come up but are applying for posts in perinatal mental health. That initiative has been helpful.

We have had to work on things like having job descriptions that are clear so once staff come they know that not only are they working in an area that is lovely to work in but it is also a workplace where there is a lot of training and support provided for them. For instance, with the psychologist that came on board, we provided supervision from the UK because we do not have that expertise within the country although we are nearly there. We provided monthly supervision for a period of a year for our own six senior psychologists working for perinatal mental health. When one wraps it all up together as a package, it encourages recruitment.

The clinical programmes are attractive areas for staff to work in because they know that they will get a wraparound support when they come in to a clinical programme. That helps recruitment in mental health in general because, for those who work in the generality of services, it is nice to know that there are other opportunities to work in different areas and they are promotional opportunities. We do help recruitment as a whole.

Dr. Amir Niazi:

It does. Recruitment is one issue but retention is a bigger issue. The support that has been provided from the clinical programme nationally to retain staff makes a difference.

Mark Ward (Dublin Mid West, Sinn Fein)
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It is refreshing to hear all that and much of what has been said is common sense. I would like this model replicated in other departments in the HSE as it would help with the recruitment and retention of staff.

Professor Anthony McCarthy:

Everybody working in mental health, irrespective of whether we are dealing with major mental illnesses or less severe ones such as anxiety or depression or serious psychotic illness, we spend our lives no matter which speciality, whether it is psychiatry, psychology or whatever, wondering where did it start, where did it begin, why did it happen and where are the multiple areas in which it can begin. One of the key things is early in life so early attachment and, therefore, any of the drug or alcohol problems are to do with security of family attachment, involvement of fathers, the care of babies right from the very beginning and the security of that. Dr. Wrigley said that this is a lovely area to work in. It is a lovely area to work in but it is a stressful one, and sometimes it is risky and highly demanding. There is a real feeling that if one can get in early then that is a valuable lifelong service, which is an aspect that helps to retain staff as well.

Mark Ward (Dublin Mid West, Sinn Fein)
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The issue of public health nurses and their importance was mentioned. In my area, parents were getting letters from the HSE to state that the public health nurse service could not deliver child services for their children's development assessment at three, nine, 11, 21 to 24 and 46 to 48 months. I was one of the people who highlighted this issue at the time. We focused more on children's developmental checks being missed. Basically, we focused on the child. Listening to the witnesses, however, it is clear that public health nurses play a role in the health, including mental health, of parents and that is being missed in this regard as well. I ask the witnesses to address this issue of children not getting developmental checks and public health nurses not visiting parents up to 48 months after the child is born in my area, including in Clondalkin, Lucan and Palmerstown.

Dr. Margo Wrigley:

The public health nurse is key in the postnatal period in terms of the close follow-up with the mother. While the focus might be on the baby, public health nurses have a holistic view of life and they will also see what is going on with the mother and inquire about that. If public health nurses are being cut, that is a major deficit. They are key.

Dr. Jillian Doyle:

Many women, even those who have had a good pregnancy or delivery, encounter difficulties in those earlier days after going home from hospital. The woman is not given a manual. She has to try to figure out how to manage this new person. It is incredibly stressful. The public health nurse coming in is a point of contact and support. Even if the public health nurse only visits once or twice, that can support the mental health of the woman, especially for many women who are quite isolated. We spoke about Covid, which has been so isolating. There are many women who do not have family here and the public health nurse is a key person for linking them in with community supports.

They also support women with breast-feeding. For many women, breast-feeding is a difficult journey. The rate of breast-feeding drops off a cliff after women leave hospital and that is due to a lack of lactation support. The public health nurse can provide that support, at least initially, to women. That contact, support and linking in with other community supports is vital, particularly for women who are isolated. It could be as simple as the nurse asking them why not contact their mental health service. Some women might have gone through their pregnancy without realising there is a perinatal mental health service. It could be the public health nurse who links them back in to that service. It is important.

Dr. Eithne N? Longphuirt:

As a support to public health nurses, primary care psychology embedded in a primary care network can provide that extra link and support for public health nurses to do their job. It allows them to come back and consult in respect of what they can do regarding a mother who has a particular issue. As primary care psychology begins to learn more about how to provide a good service for mothers and infants together, we can work with public health nurses in that regard. They come to us to consult in respect of relationships - not just the mother or the baby, but how those two are getting on together. That is vital. Reference was made to the first 1,000 days, but the first 100 days are so important for the trajectory of an infant and have a significant implication for all health services in the future. If we can get that right, it will have significant benefits for people and for the economy.

Mark Ward (Dublin Mid West, Sinn Fein)
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When I was a young new father, I had interactions with public health nurses who came out to the house to visit my child and my wife at the time. As a father, I got support by being able to ask a question because I was not sure and did not know what to do and all that. It still sticks with me that I was able to use that support and it helped me at the time. The gap in services in my area at the moment is just not good enough and that issue needs to be prioritised for women and their partners.

Dr. Eithne N? Longphuirt:

Where this is hitting is the most vulnerable in society, including those who might be more reluctant to come to services, such as those in the Traveller community or those from places where it may not be the done thing to look for that support. The person might be reluctant or have had difficult experiences.

Those are the people who we are really missing and who are really going to lose out. Those are the most vulnerable.

John Lahart (Dublin South West, Fianna Fail)
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I was not present earlier but I followed the discussion remotely. I will make some comments because many of the questions have been answered. If there is something the witnesses want to take up in that regard, I am happy to hear it. I found both presentations had different emphases and were quite evocative. Sometimes you think you have processed losses and suddenly you get ambushed when people start discussing some of the issues. I found myself very moved and touched by that.

A point I have made at meetings of the Joint Committee on Health and the Joint Sub-Committee on Mental Health is that I am very struck by the difference in approaches in Scotland and in Ireland to healthcare generally. The Scots seem to adopt, ever since the foundation of the National Health Service, this concept of having an embracing health service. We have a health service that to some degree likes to keep things at arm's length, which is a pity and that is a necessary step change. I am thinking about immigrants, towards whom Dr. Doyle gestured, who do not have granny and grandad or the aunts and uncles and that support network that translates into childcare, and it translates into so many aspects of their lives. For example, it translates, as we know, into the ability to go back into study or to take on work etc. In this particular area, it is an especially acute loss.

I am a psychotherapist by training and some of my favourite clients were pregnant women or women who had lost their pregnancies or miscarried. One of the things that would have caused me to reflect was the awesomeness of the whole pregnancy piece. To me, depression, as opposed to clinical depression, is quite understandable and a logical conclusion when a woman has carried by herself a growing baby and the awesome responsibility of that. Then there is the great birth event, but the baby is no longer part of the mother, and that represents a loss, I imagine. The idea of being depressed and feeling a sense of loss and dislocation makes an awful lot of sense to me but can be news to a mum. About 20 years ago I spent two weeks in hospital, and I remember on the journey back home feeling this sense of complete isolation because I had become very used very quickly to the institutionalisation and the care of nurses, and now I was on my own to care for myself and what if something happened? Multiply that by an infinite amount with a mother who is coming home with such a fragile delicate piece of life. Perhaps the witnesses would like to comment. Maybe somebody can note it and come back on that issue of the speed of the turnaround of pregnancy in hospital. It seems to be really quick in terms of delivery and then home. I do not know what the witnesses' views are on that. If I was a mum I think I would find it quite scary being in care and surrounded by professional care, even for a very short period, and then I am back home. A lot of this comes back to the rights of the child, and maybe that should be the point from which we start, once they are born. Obviously, there are the rights of the child in the womb in terms of being a caring environment and reflecting that, but it is just that turnaround period I am thinking of.

I am probably one of few politicians who have read John Bowlby's books on attachment, separation and loss. I know when we talk about attachment, people often think of that clinging behaviour.

One of my favourite images is of the baby crawling out of the room and exploring, and then going back in to check. The certainty that the parent and caregiver is there allows the baby to explore further. It is one of my favourite images of attachment. I ask the witnesses to address the issue of the turnaround time.

When I hear our guest use the words "mental health", there is a voice screaming in my head that we would be better to use the term "well-being". There is still a stigma attached to it. I would welcome their views in that regard.

I was interested in the witnesses' remarks on facilities. I visited the new children's hospital satellite in Tallaght, which is in my constituency. The health committee was fortunate enough to go there to see the developments in the new children's hospital. I was struck by the lengths that have been gone to, even in the satellite hospital, in terms of things such as the scent. The place does not have the classic hospital scent. Quite a bit of work has been done in that regard. Children had a significant input into the environment, art, colour scheme and all those kinds of things.

My next point is for Professor McCarthy of the National Maternity Hospital. Breast-feeding is a significant issue when it is encountered by professionals in terms of the lack of support and the sense of guilt or failure that some women may feel. They find it quite difficult to overcome that.

I refer to the mother's environment or the environment in the room. I ask Professor McCarthy to develop that theme as well. I refer to housing or the lack thereof. Anxiety and distress are experienced by women who are living in cramped conditions or on a housing list while pregnant. In some cases, they are coming home from hospital not to their own home but to a shared home environment. Some women are not lucky enough to even have that. I liked the fact that Professor McCarthy outlined that the National Maternity Hospital is clear about the functions of specialist perinatal mental services. The witnesses will all have a chance to respond when I have finished my questions.

Moving on to the PSI, I refer to the first year of care. We know the damage that is caused by separating infants from their primary caregivers. Do we still not do that well?

Going back to the needs of the child, the PSI in its written submission states: "We must learn from our history of separation and move towards combined care that supports early relationships between caregiver and baby." Where are we in that regard? That sentence arrested me. It made me wonder whether we are not a million miles away from the awful stuff that we read about.

There are one or two new primary care centres in my constituency. I like the idea of it being the model but the staffing issue in that regard is quite tricky, even in terms of GPs, never mind any of the specialist pieces.

Dads do not get a big mention. There is a gesture towards dads. It is like there is a picture of a helpless onlooker. There could have been more emphasis on moving from that to a really supportive role. What is the PSI's view in that regard?

There is the piece in respect of being out of control. Professor McCarthy made the point that suicide is the highest cause of maternal death. He referred to maternal death rather than women's death. I ask him to develop that point as I did not understand it fully.

I will finish on the point relating to the health system in Scotland. Dr. Ní Longphuirt urged the committee "to invite in the infant, the mother and the family". What do our guests think we actually do? What is the chasm? That is food for thought.

Professor Anthony McCarthy:

There were plenty of interesting questions there. The Deputy is an unusual politician in that he has read Bowlby.

I am an unusual psychiatrist in that I trained as a psychoanalytical psychotherapist and a cognitive analytical therapist. I have read Bowlby as well.

We could talk all day about the baby being inside or outside, whether is it lonely and that separation issue that was mentioned, but it is especially important that we see an individual mother. For some mothers, when the baby is inside, they feel that it is safe in there. When the baby comes out, they are terrified or worried or there is a sense of loss. For others, they feel completely out of control with the baby inside and want the baby out so they can hold it. A mother who has lost a baby before from a stillbirth or miscarriage wants that baby out. Some women are desperately attached to the baby inside. Some are not because they have three other children and people are telling them they should be attached, but they do not have time. Those women know that once the baby is born and they have a few weeks of sleep and toast and tea, they will love their baby in the long run. Everybody is different and it is desperately important to deal with the individual mother and not think that this is traumatic. It is about what is the issue for this particular woman with her history, circumstances and family, etc.

The Deputy made a reference to clinical depression to being almost normal. To be challenged by birth is very normal. All of the experiences are demanding. Some 60% of mothers are struggling. When we use the term "post-natal depression" for 11% of women, that is a very useful label simply to highlight that it is a serious time of struggle for so many women. Post-natal depression is not a thing. It is a very useful label that says, "This is a struggling time." Some women are depressed, anxious, distressed, adjusting, traumatised or have had a very difficult birth experience. For the majority of those women who are depressed, it is understandable depression, not clinical depression but it triggers clinical depression in some women. One of our jobs in terms of risk assessment is to ask if it is the normal depression everybody has had at different times in their lives if they are sensate human beings who have any cop on and life experiences versus clinical depression that we need to address. Understanding the difference is important.

On speed of delivery and leaving hospital, some women cannot wait to get out. They did not want to be in there for the birth in the first place and they want to get home, and that is a good place. Others want to get out because they are terrified and anxious; that is a sign of something else. For still others, they could benefit from the support in the hospital and, yes, because the wards are very overstretched, they are leaving earlier than they should and things are missed because of that. Again, it is always about looking at the individual person in front of us.

We could talk about mental health versus well-being until the cows come home. It is sometimes a bit like changing the name of the Windscale nuclear reactor. You can change the names, but at the end of the day, there will be a lifelong issue regarding how to name normal mental distress and difficulty and not stigmatise that versus recognising that sometimes it has moved into a situation where someone's brain is in trouble. In one person stress gives them an ulcer, in somebody else it makes their eczema or psoriasis come out or their immune system crash, and sometimes stress and challenges get into the brain and create a brain problem. It is about trying to find labels that are going to catch that accurately without stigmatising or making people react to it. I would love the time to come when people will recognise that it is not just equivalent to physical health difficulties, but equally important and valuable, and we will not get hung up about the approach to it;, we will just want to make it better, rather than worrying about stigmas. Within the five minutes we had today, I would have loved to talk about dads. When I first started in the National Maternity Hospital 26 years ago, my wife's first question was, "Will you do anything for dads?" I said, "Oh my God, the services for women are so appalling, I am just starting. Dads are going to have to wait". They are a hugely important part. We see dads frequently and accessing and supporting them is also a key part. We should have much more resources for them.

I will finally deal with maternal death. There is a difference with a death caused by birth. This classification occurs in the first six weeks after the birth or within the first year - there are different classifications. The second most common reason a mother died during the first year after birth last year was suicide. It varies from year to year. There have been years where in Britain and Ireland suicide was the most common cause, but it is always one of the top two or three causes of maternal death. That is a death within the first year after the birth of the baby.

Dr. Eithne N? Longphuirt:

I agree with everything Professor McCarthy said. I do not want to repeat anything others have said.

On the questions about dads, we are seeing LGBT+ people and families who do not look like the traditional family more often in the health service. The other piece is having a service and training that allows the clinicians working with people to feel competent, able and resourced. We have Dads, Mums, Moms and many people who go by lots of different labels and it is important we learn how to provide those people with a good service.

Two issues we were talking about come to mind in respect of the combined care of the mother and the infant. The perinatal services could do more both structurally and with the staff we have to be accessible to infants and mums. We are working in portacabins. We have a lack of spaces and are not able to see all of the different pieces that need to be seen. In our statement we mentioned the idea of infant mental health practitioners and what we mean is practitioners who can work with the dyad - mums and infants or dads and infants together - to ensure the early relationship is nurtured.

The other piece relates to when children move from the neonatal intensive care unit, NICU, to the paediatric intensive care unit, PICU, for example from the National Maternity Hospital, Holles Street to Our Lady's Children's Hospital, Crumlin when they are very sick. If their mother is still in the maternity hospital, they are separated. The fact that those resources are in separate hospitals has a major impact on the mother's ability to visit her infant. That was exacerbated during the Covid-19 pandemic when parents were separated from their infants and were not able to visit them. That happens within hospitals sometimes because it can be difficult for staff to support parents to visit their child in the NICU and to be present when the child is feeding or at other crucial points so they can realise the role of being a parent from the start, no matter how sick their infant might be. Again staff training on that subject is required, but the co-location of hospitals also has a major impact on parents when their child is very sick.

Dr. Jillian Doyle:

I will pick up on a few points.

As regards well-being and mental health, when I am working with people, I often think I am initially treating their mental health. An absence of a mental health difficulty does not necessarily mean people are feeling well or are happy with their quality of life. I am always trying to think about how to work with both and help people build a life they feel is worth living that gives them joy and contentment. We need both because that helps them access their threat or "fight or flight" system in a way that helps them live their life in a way that is beneficial. We do not want to get rid of the ability to detect danger or to respond to threat, but we want people to be able to move out of it when appropriate and to access support and resources that nourish them.

It is important for people from other countries who have come to this country to be able to access supports. One of the supports we can provide therapeutically is group work. I feel a bit like Oliver Twist asking for more because we have some clinical space in the Rotunda Hospital, but not enough and none of us has access to group rooms. Groups are important for mental health. If I had a magic wand, I would make a nice baby-friendly group-room where we can get down on the floor. Babies do not like to sit on chairs. Small babies cannot sit on chairs and it can be hard for a mother to have to keep her baby in a buggy for an hour. Babies are good communicators and it can impede the mother's communication if her baby is crying.

We also do not have baby changing facilities in our fancy portacabins. That is a practical issue. A mother needs to have easy access to a toilet and baby changing facilities. We were talking about bricks and mortar. That is what we need to help people access services.

Thinking about becoming a mother, matrescence or the journey towards motherhood, happens throughout pregnancy and in the perinatal period.

We become mothers throughout the life span of our children. A woman is learning a new part of this identity of being a mother in each milestone of development. When Deputy Lahart spoke about that, I thought about teenagers, whom we highlighted in our report. It can be difficult being a teenage mum. The people in your social circle are not going through the same experience as you, so who do you have to bounce this developing identity off? It is an opportunity to bring that to the fore again, that these young women, these mothers, really need our support and our help.

When Deputy Lahart talked about turnaround speed, I thought about trauma-informed care. Some women would very much appreciate an extra few nights in hospital, but some women want to get home to their family as soon as possible. That is one of the things over which we need to give the woman control. What works best for them, what works best for their family and how do we support that? Community midwives have such an important role to play where women are maybe leaving hospital faster than would have happened historically, and of course there are the public health nurses for continuity of care.

It would be amazing to have accommodation that does not smell like a clinic or hospital and that is baby-friendly. On accommodation, we are seeing people coming into our services who are living in really difficult circumstances. In the Rotunda we have people coming from direct provision centres where a woman may have come through unspeakable trauma and is now living in a place she feels is not ideal for her and her circumstances and she does not know where she will be going next. The importance of giving people certainty cannot be overlooked when we are thinking about how to make someone feel safe. If you do not feel safe, how can you help your baby feel safe? Something I always think about when someone is referred to me is where they are living. That is the starting point. If we go back to the basic hierarchy of needs, we need to make sure someone has somewhere to live where they feel safe.

The Deputy mentioned people feeling out of control. Thinking about birth trauma, oftentimes if someone has an experience of birth trauma, they are left feeling very out of control and very disempowered. It is a very important function of all our services to give a woman back control and to educate her antenatally about what is going to happen. This involves giving education around babies and what it is like to have a baby, that women might feel depressed and overwhelmed, and where that goes from being normal to abnormal. It is also helping someone think about the fact there is a point during birth where they are out of control because the body takes over, and in our society we are so in our heads and we want to know and to be in control. This is probably the most in your body experience a person will go through. It is a case of trying to explore what it is like for them when they are out of control and how we help them to stay with themselves in that.

Dr. Margo Wrigley:

I hope my colleagues have answered to Deputy Lahart's satisfaction many of the points he brought up. One area I would like to mention in the context of the early discharge after a day in hospital is the small but nevertheless very important number of women, probably around 120 per year, who develop postnatal psychosis, which is a very serious mental illness. I use the word "illness" in this context. That occurs typically within days or so of birth, and if a woman is out of the hospital within a day, it may be that it does not happen when she is in the maternity service but it may happen when she is at home and she has less support. Where there has been a previous episode of postnatal psychosis, obviously there is very careful surveillance kept specifically by the perinatal service mental health services to make sure the woman gets the care she needs.

If it is a first episode of postnatal psychosis, it can be a very worrisome time for women. It is something I am aware of because women are only staying in hospital for a short time after giving birth.

There has been some discussion of terminology with regard to mental health problems, including terms like "mental illness", "psychiatric illness" and "well-being". I will make a general comment on the difficulty we experience in that regard. Dr. Niazi would experience this more than me in his current role. While people are much freer about saying they feel unwell mentally and talking about feeling anxious and depressed and so on, when you are talking about people who have severe and enduring mental illness such as schizophrenia or bipolar disorder, there is not as much of an acceptance of that. The acceptance needs to be there so that it is followed by an impetus to develop services to meet patients' needs. That needs funding as well. Does Dr. Niazi want to say anything further on that?

Dr. Amir Niazi:

This is an important area in our other programmes, especially the early intervention in psychosis programme. Early detection and intervention is key to all the clinical programmes that feed in and that we look for.

Frances Black (Independent)
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Does Deputy Hourigan want to come back in?

Dr. Margo Wrigley:

What a wonderful question.

Dr. Margo Wrigley:

The Deputy is eliciting a high emotional response in me because our hearts are broken trying to get a system in place to collect data. What we are working off at the moment are Excel sheets. Essentially, we are looking at who comes in and who goes out. It is a completely inadequate system and we have been working on it since we started. Dr. Niazi has been wonderful in supporting us in trying to get a bespoke data system. We would like it to have a unique patient identifier number, obviously without knowing the patient's name, so that we could follow the patient's clinical pathway from start to finish. This would enable us to know how and why they came in, what sort of help was provided for them and by whom, what sort of an outcome they had and, very importantly, what they thought about what they were offered by the service. We were making some headway with that until the cyberattack happened and then progress went backwards.

Due to the concern about a further cyberattack, a tight process is in place and we are not allowed to look at a bespoke data system at all. We are looking at alternatives and most recently, as Dr. Niazi knows, we set up a little subcommittee within our perinatal world to look at the data we are collecting and refine it. We now have a link in with the National Perinatal Epidemiology Centre in University College Cork. It already collects data for the national women and infants health programme on things like perinatal deaths, brain cooling and so on and because it is already involved with the HSE, we can use the centre. We hope to be able to provide better data but we will still not be able to provide the unique patient identifier and, therefore, it is still not enough. We absolutely need that because unless we have data like that, we do not know whether we are doing the right thing or not. We hope we are. We talk to women and we have a project in place where we will get feedback from women. Parts of the system like the Coombe Women's Hospital did a study looking at feedback from women accessing their perinatal mental health service, but we need to have a whole-system view of it so we can get exactly that data. We would welcome the Deputy's support on that.

Dr. Amir Niazi:

I thank the Deputy. The HSE definitely needs to do a lot of hard work to make progress in this area. Some of that is under way. Each of the clinical programmes I mentioned has its own unique needs as to how we collect the data for them. I liaised with all the national leads to see what their needs were. The self-harm programme, which works with the National Office of Suicide Prevention, had its own needs as did the perinatal programme working on women's health. We tried to put all of those needs together and to look for a system that could collect those data. Money was even allocated for us to go out and buy the software to develop our own data system and then when the cyberattack happened, we were told that the HSE was currently using approximately 2,000 different types of software in different parts of the country on different programmes. Everything was halted. We were told that the skeleton system, the integrated community case management system, ICCMS, which will use the unique identifier number, was being developed and when that system was in place, the 2,000 different types of software would have to be looked at as regards speaking to the main skeleton. Whichever software works with the main system would be the one they take on.

Dr. Amir Niazi:

I would love to say that they did.

We have already identified what our need is. We even know what system we need, but the problem is basically getting it over the line. The HSE said it wants to make sure the software we are looking at can pass the scrutiny of safety and all of those things. That is where we are at. I can give an example, not for the perinatal programme but for another area in the HSE. We were brought to Copenhagen to be shown how good their systems are but when we looked at the whole system, we felt we had most of the nuts and bolts of it. The only thing we were missing was talking to each other and bringing the data system together, which can collect that information, share it and use it. Once we address that area, we can definitely stand over it and say that we are delivering a much more united service.

Frances Black (Independent)
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I have been blown away by the presentations. I can see the phenomenal work that the witnesses are doing and I thank them for it.

I have a couple of questions. The one area I have a particular interest in is the teenage pregnancies. Am I correct that they are excluded from perinatal services? Did I hear this right?

Dr. Margo Wrigley:

We are adult services, so the psychiatrists working with them are licensed to see adults. However, what happens with teenage pregnancies where there is a mental health problem, if a child and adolescent psychiatrist is involved, there is then liaison so that there is adequate input. Professor McCarthy might be able describe that a better than I am since he has done it on the ground.

Professor Anthony McCarthy:

I am sorry; I would break my licence.

Dr. Margo Wrigley:

Sorry.

Professor Anthony McCarthy:

Certainly, if an adolescent presents in Holles Street with mental health issues, the team or I will certainly see him or her. We very often refer to adolescent services in the community. Certainly, I would never refuse to see an adolescent and I have seen some adolescents right through pregnancy.

Frances Black (Independent)
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Are they being looked after and cared for?

Dr. Margo Wrigley:

We are being flexible, as Professor McCarthy outlined. As I said, we have done so much and there is more to do. Certainly, we would like to have child and adolescent mental health services aligned with the services as well. If Sharing the Vision, which talks about further development of those services, comes into being, that might help. This is an area where we have tried to do the best we can within the confines of what we have but it needs more attention, as the Chair rightly said.

Frances Black (Independent)
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Are healthcare professionals able to recognise somebody who might be suicidal? Is there an intervention process around somebody who might be suicidal? How do they recognise somebody who might have an alcohol problem? How does all of that work?

Dr. Margo Wrigley:

That would be part of the routine examination of anyone who presents with a mental health problem. They are asked about what is troubling them at the time and go into the details of that. There would always be a question about the use of alcohol, the use of drugs and so on. That is recorded and dealt with if it is a problem.

On suicidality, that is always asked when the mental state is being examined. There is this myth that if the question is asked, it will put the idea into someone's mind. However, that is absolutely not the case. It is much more likely to find out that people have these ideas. If we know about them, we can then try to work with them to provide whatever assistance they might need. Those two areas are always dealt with with every person who presents with problem.

Professor Anthony McCarthy:

That is part of the overall mental health assessment. Whether it is a psychologist, psychiatrist, psychiatric nurse or any mental health professional, it is part of our job to do that and, obviously, to take it further than that.

We spoke about facilities and having one office available for eight people. When we see somebody for the first time, it is for one hour. A new appointment is for one hour but a lot comes out in an hour if we engage and connect with the person as, I hope, we do in most cases. Everything comes out. Again, one of the lovely parts, and privileges, of this job is that it is often a time in women’s lives when they are likely to be more open. They are concerned and worried. If they are drinking or suicidal and having those thoughts or intentions, it is probably a more likely time in their lives to say than other times are. However, that is not always the case, of course. Most of the time, trying to confine it to the hour is the difficulty, rather than things being hidden, truthfully. Part of our skills is to be able to check if someone is depressed, has any suicidal thoughts - who has not had them at times - suicidal intentions, specific plans and what would stop them. It is working on that or whatever the issue is. It is trying to open that up. Hopefully, with the ongoing training they get, our teams are good at listening and providing the space in which that issue comes up. At the end of the day, most people who are feeling like that want to talk about. They just want to know this is a safe place.

Frances Black (Independent)
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The witnesses touched on this but I would like to get an overall view of the wish list.

Let us say, for example, that our witnesses get everything they wanted today. Can they describe what that would look like? I do not know who wants to start.

Dr. Amir Niazi:

If the Chair is talking about the perinatal programme, the mother and baby unit is number one on that wish list.

Frances Black (Independent)
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Should there be one or a few units? This is Dr. Niazi’s wish list.

Dr. Amir Niazi:

There would be three. Another wish would be to have appropriate accommodation for the three HSE maternity hospitals in Cork, Galway and Limerick.

Dr. Margo Wrigley:

And a bit more in the voluntary hospitals as well, to be fair.

Dr. Amir Niazi:

Another would be for a data system that can give us the right information on what the services are and how we are delivering, monitoring and collecting all of that. If I could have these, I could certainly say we are delivering a good programme and stand over it.

Dr. Margo Wrigley:

Can I add to those?

Frances Black (Independent)
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Sure.

Dr. Margo Wrigley:

Assuming those ones still stand, we would like to have additional perinatal psychiatry time for some of these hub hospitals so we can support the spokes in the way I outlined. We have that for the Saolta Hospital Group, but we also need that for the Rotunda Hospital and the national maternity hospital in University College Cork, UCC. Limerick does not have spokes. We also need additional administration staff in at least three of the hub hospitals. As I said, we see them as very important.

Outside our service, in the model of care itself, we have listed the large number of services that are concerned with perinatal mental health. We are looking at a particular aspect of it, but there is much more to do. The areas I would cite would be primary care and psychology, which have been referred to. We would like the public health nursing workforce to be properly expanded to ensure more visits in the way that we have talked about.

There is a need for specific mother and infant attachment services. This is not for the women we see who have significant mental health problems, but there are also women where there may also be attachment problems developing outside that. For instance, where babies have spent a protracted period of time in neonatal intensive care units, that may be a problem. There are also women with, shall we say, personality disorder, who may have attachment problems and could also benefit from those sorts of services as well.

There is the whole area of infant mental health, which takes the child up to the age of three, for which we have no services available in Ireland. They are not developed within our overall child and mental health services. However, they need to be looked at as well.

I am being very ambitious. I am just saying that we have that list. We see ourselves as providing for mild through to severe mental health issues arising in women attending maternity services. We are developing the training and linkages so that others involved, such as GPs, public health nurses and so on, can link into community mental health teams – that side of things. However, there is a huge need for investment in infant mental health. That needs attention.

John Lahart (Dublin South West, Fianna Fail)
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I have a final question on Covid, to which Deputies Ward and Hourigan referred. I referred previously, albeit in a different context, to a great book written by Dr. Ida Milne on the history of the Spanish flu in Ireland. One of her conclusions, which she laments, is that the Spanish flu occurred in a period of revolution towards the end of the First World War and people did not want to know or talk too about it much. As such, we forgot about it as a society and, as Dr. Milne wrote, did not memorialise it. Memorials take many different manifestations.

I sense an appetite in Ireland to try to move on from Covid very quickly. It looks as though we could have more than another pandemic in our lifetime and we are not completely free of this one.

All Deputies heard heartbreaking, heart-wrenching and awful stories about dads or partners waiting in a car outside the prenatal clinic and not being present at labour. What have we learned? Where can we learn about that? The papers have not been written about this yet. This is not about looking for headlines to point the finger of blame but, if in ten years' we had another pandemic that necessitated interventions such as those we have just had, what could our prenatal and postnatal care system have learned? Was the response proportionate in hindsight? How would we do it again? Part of that paper, whenever it is written, is about acknowledging the awful trauma experienced by mothers and their partners and, equally, the trauma of the nurses and nurse managers who had to say "We are sorry". I am sure they put up with considerable abuse and trauma.

Mark Ward (Dublin Mid West, Sinn Fein)
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Someone rang me about getting advice from public health nurses around partners. One of the opening statements said that little or no service provision had been developed for partners in the perinatal period, including those within the LGBTQ+ community. Are there any international best standards for addressing this and how quickly can this be incorporated?

Dr. Eithne N? Longphuirt:

I do not have the best practice standards off the top of my head. There are best practice standards from the UK but I would have to find them. I do not want to misquote them. One of the foremost pieces is around training and awareness and upskilling staff with regard to LGBT+, in particular. That does not just mean the perinatal teams. All of the staff in maternity hospitals need support and training, because there will be more and more people from that community who need to be supported and to be treated equally, yet differently. They have had disproportionate amounts of mental health difficulties and suicidality, by comparison with the general population, and all of the research says they have had difficulties accessing health services in general in this country and internationally. We need to care for that population but the foremost piece is around training and support of staff as a start.

Dr. Margo Wrigley:

A number of us who were working within the mental health programmes during the first year of the pandemic in 2020, including Dr. Niazi, got together to write a paper on the psychological impact of pandemics and specifically Covid. There were very little data from the flu epidemic after the First World War, or the Spanish flu as it was called. However, there is considerable information on the subsequent SARS pandemic in south-east Asia, in particular. The paper talks about a tsunami in the later stages of the pandemic. After getting over the physical aspects, there can be a tsunami of psychological impacts of the pandemic. This is not well recognised but has certainly been documented in previous pandemics. There is evidence of such an impact now. I do not know of any work that was done but we were very keen, within the mental health programmes, to flag it rather than have people say the pandemic is done and dusted and we do not need to worry. Many people are still suffering.

We see this business of coronaphobia and being afraid to go out all around us and in our own families. It is a very real phenomenon. I cannot speak from a clinical perspective but my clinical colleagues in perinatal might be able to say whether they have seen it in the context of women who have attended their clinics.

John Lahart (Dublin South West, Fianna Fail)
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I can understand the context when I look back. My late mother spoke about the revolutionary period but never mentioned the Spanish flu. There are similarities. We have a war on the Continent of Europe and a big energy crisis. It is not that people have forgotten the pandemic. It is just that other things have preoccupied us. We must, however, learn from this.

Dr. Eithne N? Longphuirt:

We spoke earlier about the importance of control for women and their sense of efficacy when they go into services. Some of the more qualitative research on the pandemic has talked about uncertainty and the impact that has had on women, that is, uncertainty about what services would be provided for them; whether they would be lucky to see a month where restrictions had been lifted; whether restrictions would be lifted in the hospital they were to be in; and whether their partner would be able to come in and for how long. Such uncertainty has had a considerable impact on women.

As people who provide a service, we have seen a much higher influx of postnatal women accessing our services, many of whom will say they do not leave their house except to come to the service or that it is their first time and their beginning. It happens less than it did a year ago but it absolutely happens.

We talked about infant mental health. There are women who worry about their infants and whether the lack of community involvement in those first few years has had an impact on their two- or three-year-old. It can be very hard to decipher whether it has had an impact and what we are looking at. People need support. There has been a considerable increase in anxiety. International papers say that the levels of perinatal anxiety have gone up because of Covid.

Dr. Jillian Doyle:

It is interesting because we are now seeing people coming back with a subsequent pregnancy who are quite traumatised from their previous pregnancy and are trying to negotiate the subsequent pregnancy in a different way.

Professor Anthony McCarthy:

We all need to know there are multiple sides of it. We are all learning and continue to learn. The evidence base will keep changing. We had a recent support meeting in Holles Street hospital about Covid. Our clinical director was describing how when Covid hit in March 2020, he was having to tell staff they must come into work in our beautiful and old, but cramped, building which was designed for 2,000 pregnancies per year but actually has 9,000, while thinking that if Italian figures were to go through that between 35 and 45 of the staff in the hospital would die.

Medical staff often die in pandemics. If one looks at pandemics all over the world, medical, nursing and other staff die. I was past retirement age but I was going into the hospital, as were many others. We were very aware of the risk to ourselves. We were also very aware of the risk to the mothers. We were doing everything possible in our cramped building. The Deputy mentioned there may be another pandemic within ten years. I hope the new national maternity hospital is in St. Vincent's hospital within ten years where we will have single rooms at that stage and will be able to allow dads in.

We were very aware of the safety of the mothers. Can we win? We did not want to give Covid to mothers and we certainly did not want to give Covid to babies. It was pre-vaccines. We were aware of how dangerous it would be in pregnancy for mothers who were not vaccinated. We did not have vaccines yet. We were worried about ourselves in that context but, more important, we were worried about the mothers and the babies. We do not want even more court cases with people suing the hospital for giving Covid to a mother because we did not protect them well enough.

The pandemic has had all sorts of effects. Many mothers and parents missed out. Some were thankful that there would not be loads of husbands, partners, grannies and others and that they would have their own space. Others were delighted to go home and not have family visiting all the time. One has to see the individual and work around that individual.

John Lahart (Dublin South West, Fianna Fail)
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Again, and it is not a finger-pointing, headline-grabbing exercise, but was the response proportionate? Have we any evidence to say it was a proportionate response, or that knowing what we know now, if we were to go through it again in exactly the same way, things would be done differently? We had representatives of the HSE before the committee and the buildings were highlighted as being a big issue. I am asking about the proportionality of the response.

Professor Anthony McCarthy:

It is very hard to tell. There were pros and cons. We are all learning. In response to Deputy Ward's question, we are all learning about how to deal with LGBT patients. We are seeing much more of it. We we are seeing our very first patients. We are seeing donor eggs and the complexities around that. We are dealing with patients who are having their babies elsewhere. We are even seeing transgender males, who have not had a hysterectomy yet, who are stopping their treatment to have babies. We have men coming in to have babies. We are learning all the time. On the question of whether there are best practices, we will have to work on them. We are learning all of the time and we are trying to improve our services in that way.

Frances Black (Independent)
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I thank the witnesses. After listening to them all speak today, I feel our perinatal services are in very good hands. If only the practitioners could get exactly what they are looking for, we could definitely be one of the leading countries in the world in perinatal services, as Deputy Ward said. I feel our perinatal services are in very safe hands. I thank the witnesses for their passion in this area in particular. I wish all our health services staff were as passionate as the witnesses are. I thank the representatives of the Psychology Society of Ireland, the HSE and the National Maternity Hospital for contributing to this discussion on perinatal mental health. We will definitely to our best to support the organisations represented going forward. We will highlight the issues raised as much as we possibly can going forward.