Good morning. No apologies have been received.

Today the committee will consider the National Maternity Strategy 2016-2026, including progress on its implementation. To assist the committee's consideration of this matter, I welcome, from the Pregnancy Loss Research Group, Professor Keelin O'Donoghue and Dr. Marita Hennessy; from Féileacáin, Ms Mairie Cregan and Ms Anne-Marie Farrell; and from the Irish Nurses and Midwives Organisation, INMO, Mr. Tony Fitzpatrick, director of professional services, and Ms Aisling Dixon, midwife.

I will read a note on privilege. 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 may be regarded as damaging to the good name of a 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. It is imperative they comply with any such direction.

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 by name or in such a way as to make him or her identifiable.

I will read a note on attendance by members. I remind members 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 members to participate if they are not adhering to this constitutional requirement. Therefore, members who attempt to participate from outside the Parliament will be asked to leave the meeting. In this regard, I also ask members participating via MS Teams that, prior to making their contribution to the meeting, they confirm they are on the grounds of the Leinster House complex.

As noted, today's session will focus on maternity services and the implementation of the ten-year national maternity strategy, which is now in its last year. This is the first of two sessions dedicated to the strategy. Today's session will have a particular focus on staffing and pregnancy loss. We all know that staff in our maternity services do incredible work, but it is too often in substandard conditions. This point was made evident this week following An Coimisiún Pleanála's decision to refuse planning permission for the critically needed wing in the Rotunda Hospital.

Today's session is important for another reason. The committee is keen to put a real focus on pregnancy loss and the supports and services that should be available to bereaved parents. This has been overlooked historically as an area of maternity care and the next strategy provides an opportunity to address this and to deliver consistent pregnancy loss services and supports across the country.

I am looking forward to the engagement this morning on these issues. To commence our consideration of these matters, I now invite Professor O'Donoghue to make her opening statement on behalf of the Pregnancy Loss Research Group.

I thank the Cathaoirleach and members of the committee for the opportunity to meet today to discuss issues relating to the national maternity strategy. I lead the Pregnancy Loss Research Group, which is co-located between the department of obstetrics and gynaecology and the infant centre at University College Cork, UCC, and Cork University Hospital, CUH.

At the PLRG, we lead policy and practice-relevant national research across all forms of pregnancy loss and pregnancy endings.

I am joined today by my colleague Dr. Marita Hennessy, senior researcher. I also wish to acknowledge Féileacáin, also presenting today, with which we collaborate.

The national maternity strategy and associated national standards for bereavement care following pregnancy loss and perinatal death were developed within the context of the publication of several reports that highlighted significant deficits within maternity services. I wish to highlight three areas in my opening statement to the committee: there have been many improvements since the introduction of the maternity strategy and standards; there is still more to do to fully implement recommendations and sustain them; and there are opportunities to do much more in the next iteration of the strategy.

The maternity strategy delivered a strategic framework and, along with bereavement standards, has resulted in several improvements. Perinatal death statistics and pregnancy loss feature at length in the strategy's opening chapter. However, while many actions within the strategy are relevant, only five explicitly relate to pregnancy loss. These actions state that the HSE's national women and infants health programme, NWIHP, will implement the standards and provide additional supports and appropriate spaces, access to early pregnancy units and enhanced perinatal pathology services.

The bereavement standards established a national framework for compassionate, equitable and multidisciplinary care, driven by collaboration among key interest holders. A 2021 evaluation highlighted 40 recommendations to enhance implementation. NWIHP's structures and support have kept the standards work operational. Key achievements include clinical midwife-nurse specialist posts in bereavement and loss; expansion of perinatal pathology services; a national pregnancy loss website; education programmes; counselling and support services; and audits of the 19 maternity units in hospitals.

The work of NWIHP's clinical guideline programme has enhanced the work of the bereavement standards through the development of key guidelines in pregnancy loss. PLRG research has guided implementation and service improvements, education needs and information resources. A review of bereavement standards implementation is under way and we can share that report in time with the committee.

There is ongoing work that needs sustained support. We know from our research and evaluation of the bereavement standards implementation that more needs to be done, with variation nationally. In HIQA's maternity bereavement experience survey and in our national study on recurrent miscarriage, one in four people rated their care as "poor". Bad communication, lack of follow-up and lack of dedicated spaces were consistent findings. In addition, while many inquiries into baby deaths have happened, recommendations have not been consistently implemented and the same issues persist. The approach to reviewing perinatal deaths is not uniform or transparent and bereaved parents are often not involved.

We need to ensure clinical midwife-nurse specialists in bereavement and loss roles are protected. We need to provide additional supports, that is, resource new specialist midwifery roles for early pregnancy and pregnancy after loss. We should implement the model of miscarriage care informed by the RE:CURRENT project. We need to resource implementation of clinical guidelines, achieve specialist perinatal pathology networks and develop and implement national standards for early pregnancy units. These are elements that need national standardisation, despite regionalisation, to ensure people receive the best care, regardless of where they live or their means. NWIHP should have the authority and sufficient resourcing to continue this work. Investment in information resources, staffing, training, infrastructure and research remains critical.

Where to from here? We can harness the opportunity to further integrate measures to reduce preventable baby deaths within a new maternity strategy. Over the past decade, significant progress has been made through implementation of bereavement standards. While ensuring that people receive the best care after pregnancy loss, we also have a duty to prevent avoidable baby deaths. Ireland's perinatal mortality rates have room for improvement and minority ethnic groups are over-represented. Political leadership and targeted investment could reduce the number of baby deaths but, unlike other countries, Ireland has no action plan. While there are costs involved, these must be weighed against the far greater costs, for all involved, of doing nothing, and any improvements bring wider benefits for maternity experiences and outcomes.

This month, we are finalising an action plan to end preventable baby deaths in Ireland, developed in partnership with Féileacáin and the national perinatal epidemiology centre. We can share this plan with the committee once it is complete. It should be in the next maternity strategy.

While there have been many positive developments since the publication of the national maternity strategy and bereavement standards, there is work to be done to sustain these and further implement recommendations in key areas. There is also an opportunity in the next strategy to sustain and scale up improvements, enhance early pregnancy and pregnancy after-loss care, and implement targeted measures to end preventable baby deaths.

Good morning, a Chathaoirligh, and members of the committee. I thank the committee for the invitation to meet with it today. I am the co-founder of Féileacáin as well as a standing member of Patients for Patient Safety Ireland. I am a bereaved parent, mother to Liliana who died the day before she was due, and James, who died in the mid-trimester of pregnancy. I am also a bereaved grandparent; I am grandmother to baby Darragh, who died at three days old, following a "perfect" pregnancy. I am joined by my colleague, Ms Anne-Marie Farrell, whose son Ruairí was stillborn unexpectedly on his due date, again after a seemingly healthy pregnancy.

I acknowledge the Pregnancy Loss Research Group, whose research Féileacáin supports through funding and also active participation. In addition, we salute the Irish Nurses and Midwives Organisation, knowing full well the crucial role its members play in providing front-line care, comfort and support to our families. We also acknowledge the role played by NWIHP in working to improve care and involving the bereaved parents in these initiatives.

Féileacáin is a not-for-profit organisation providing support to anyone affected by the death of a baby around the time of birth. The loss of a baby during this period is widely recognised as one of the most traumatic experiences a family can endure. A key aim of Féileacáin is to ensure that every parent and family member in Ireland will have the opportunity to create precious memories with their baby at the time of their loss and to access appropriate support services afterwards. Through our direct personal engagement with bereaved parents, Féileacáin is uniquely positioned to advocate on their behalf. We aim to promote improvements in bereavement care and also to end preventable baby deaths.

Let us begin with a statistic that is stark and largely unknown. In Ireland, more babies are stillborn or die within the first 28 days of their lives than there are tragic deaths on our roads annually. While we have seen the powerful road safety campaigns by the Road Safety Authority, RSA, baby deaths remain heartbreakingly in the shadows, thereby missing opportunities to improve bereavement care and end preventable baby deaths.

It is a common myth that baby deaths are just "one of those things". However, many of these baby deaths are preventable and, unfortunately, every pregnancy is at risk. An analysis of 12 years of stillbirths in Ireland revealed that only a minority of the mothers had a body mass index, BMI, greater than 30 or smoked; the average age of the mother was only 31.7 years; and 40% were first-time mothers. Over a third of these stillborn babies were at term, when babies were considered to be fully developed and ready for delivery. The babies appeared healthy, with 70% of the infants at normal weight. These families had not only imagined taking their baby home; they were lovingly prepared with newborn clothes, a pram, a car seat and baby items that their child would never use. We know that twins account for approximately 10% of all baby deaths, despite representing only 3% to 4% of total births, yet we continue to see twin deaths of babies with major congenital anomalies, born at 28 weeks gestation, occurring in hospitals without the appropriate neonatal care expertise. While the maternity strategy focuses on supporting vulnerable groups, regrettable inequalities persist. Baby deaths disproportionately affect families from our black, Irish Traveller and Asian communities.

I will share some specific concerns regarding health and well-being, safety and quality of the strategy, and the bereavement standards. We acknowledge the maternity strategy's focus on empowering women to make informed decisions about their care. However, significant gaps remain in antenatal education and adherence to clinical guidelines. We continue to hear of tragic cases where medical assessments for reduced foetal movements - sometimes the only warning sign that a baby is unwell - were delayed, missing the vital window for intervention. To be clear, this delay is not the mother's fault. Patient information leaflets, which are part of the clinical guidelines, are not provided to mothers so that they are aware that this is an issue.

Myths about foetal movements, such as "drink something sugary to get the baby moving", are worryingly widespread and they are believed. Recent discussions with politicians indeed revealed that they were surprised to learn that this is, in fact, a myth. Another concern is the number of pregnant women who use the Internet for information, where information about pregnancy is of variable quality. This includes some of the Google searches through websites of Irish hospitals and this specific example illustrates the issue that is just one of many instances where there is a failure in the implementation of the strategy.

Regarding quality and safety, we commend NWIHP on publishing over 20 clinical guidelines related to pregnancy since 2021. However, the work is incomplete, with seven of the guidelines due for update and 18 commissioned, and there is no reporting on implementation. For the successful delivery of the strategy, we ask for dedicated resources to complete and implement all of the guidelines.

With regard to coroners and inquests, the distress caused to bereaved families by the coronial process cannot be overstated. Delays, lack of transparency and lack of appropriate support add to the already unbearable grief of bereaved parents following the loss of their child and we know of some areas without a perinatal pathology service at the moment. This needs to be addressed as a matter of urgency. We as parents believed there were learnings from every review and every death but we know now that might not be true.

Moving to bereavement care, we welcome the updated publication of the national standards for bereavement care following pregnancy loss and perinatal death and we are grateful for the incredible work and dedication provided by bereavement midwives and other midwives to our families. However, we continue to hear of a wide variation in the standards of bereavement care throughout the country. Many of our families are supported in making precious memories with their baby in the short time available to them, such as bathing their infant, taking photographs, dressing the child, creating precious imprints and bringing their son or daughter home. There is only one chance for bereaved families to make these precious memories and, concerningly, we hear from families who did not receive the same care or support. Sometimes, it is as simple as no one in the hospital contacting us so we can come in and take precious imprints. Other times, the bereavement midwife only works Monday to Friday, nine to five, or the post is unfilled. Babies do not always die during office hours, and the same care and support needs to be available to you whatever time your baby dies. We hear from families about the anguish of being in a space where they could hear crying babies while their own child remained silent, and from some families who received no follow-up from the hospital. We ask for all staff to be trained to support bereaved families, as well as the filling of posts and full implementation of the bereavement standards. Organisations like ours play a crucial role in research and in the support and education of those involved with bereaved families. We pledge our support to future initiatives.

Looking ahead, we are optimistic about the development of the successor to the national maternity strategy. It is crucial that the next strategy incorporates the positive learnings and addresses the shortcomings of the current plan. Furthermore, it must be informed by changes in the demographics and characteristics of women since the first strategy was published. We welcome the opportunity to return to the committee to share the ending preventable baby deaths action plan, which we believe will be a valuable input into the next strategy.

We thank members for their attention and for listening to us. We acknowledge the maternity strategy's progress but we must confront the silent truth that over 300 babies die every year during pregnancy or around the time of birth. This does not count the hundreds who die in the mid trimester or the thousands lost through miscarriage. We need full implementation of the standards.

Good morning, Cathaoirleach and members of the committee. I am director of professional services with the Irish Nurses and Midwives Organisation. I am joined by Aisling Dixon, who is an advanced midwife practitioner in Portiuncula University Hospital and who also works as part of the HSE's home birth service. Our president, Caroline Gourley, is also in attendance.

The INMO represents the majority of midwives and nurses working across maternity services in Ireland. We welcome the national maternity strategy as a progressive, woman-centred framework grounded in safety, quality and choice. However, as the strategy reaches the end of its ten-year term, delivery remains uneven and constrained by persistent workforce shortages, insecure annual funding and the absence of a fully resourced workforce plan.

Midwives are central to safe, high-quality maternity care. They provide expert holistic care before, during and after birth, they support physiological birth and continuity of care and they improve outcomes and experiences for women and babies. Yet maternity services are under sustained pressure. Despite rising demand and increasing clinical complexity, the number of whole-time equivalent midwives employed in the public service has been static since 2019. Our members report that safe staffing levels are routinely not achieved, with the recommended midwife-to-birth ratio of 1 to 29.5 not being met in most services. This is a patient safety issue, a staff well-being issue and a service sustainability issue. Policy ambition without safe staffing is not deliverable. Indeed, culture eats policy for breakfast.

The commitments in the national maternity strategy and Sláintecare, including continuity of care, expanded community services and genuine choice for women cannot be realised in an overstretched system. This is why the INMO is calling for safe midwife staffing to be placed on a statutory footing, with the mandatory, fully funded national roll-out of the Birthrate Plus methodology as the evidence-based standard for maternity workforce planning. Safe staffing must be underpinned by legislation if it is to be implemented consistently and sustained over time.

Workforce planning must move beyond short-term annual funding cycles. The absence of a fully funded, multi-annual midwifery and nursing workforce plan has repeatedly undermined implementation of the strategy. New services and pathways have been introduced without the necessary staffing investment, placing further pressure on already overstretched teams. Recruitment alone will not solve this problem; retention is now a critical issue. A large proportion of midwives we surveyed reported considering leaving the profession due to workload, stress and lack of support. If experienced staff continue to leave faster than we can replace them, no reform programme will succeed.

Women and families engage with maternity services with one central expectation: the safe birth of a healthy baby with an adequately supported mother, supported by respectful communication, continuity of care and access. This is only possible when women are fully informed and consistently supported throughout pregnancy, labour and birth.

Reform of the model of care has been too slow. Maternity services remain overly dependent on hospital-based, medicalised models. Access to community midwifery, supported care pathways, home birth and midwifery-led services remains limited and uneven across the country. Ireland has only two midwifery-led units, despite strong international evidence that midwifery-led care is safe, cost-effective and associated with fewer unnecessary interventions and that it delivers better experiences for women. Expanding community and midwifery-led care is essential if we are to deliver genuine choice and reduce avoidable intervention.

Regional and smaller maternity units are particularly vulnerable to workforce shortages. While the network model envisaged in the strategy has merit, any service configuration must be underpinned by funded workforce planning. Regional units are critical to maintaining local access, continuity of care and equity of choice for women and families. Service change driven by staffing deficits rather than planned investment risks widening geographical inequalities. This has been to the fore in the situation that has arisen in Portiuncula hospital.

Workplace culture matters. Safe maternity care depends on psychologically safe environments where staff are supported to raise concerns, learn from adverse events and work in partnership with women and families. Leadership, workforce planning and culture change must be addressed together if we are to build a safe, sustainable maternity service.

The national maternity strategy provides a strong policy foundation but it cannot be delivered without sustained investment in the nursing and midwifery workforce. Maternity services cannot function without midwives and nurses. Investment in this workforce is investment in safety, sustainability and good outcomes for women and babies. The INMO urges the committee to recommend legislation for safe midwife staffing, including the national roll-out of Birthrate Plus.

When I speak about safe midwifery staffing legislation, it is important that all the research from around the world supports this. It cannot be left to the whim of budget holders and those who decide in those areas. We also call for a fully funded, multi-annual midwifery and nursing workforce plan, targeted recruitment and retention measures and expanded education capacity. The HSE has a "Bring Them Home" campaign but nobody knows about it, particularly those in the UK and Australia. We also call for protection of regional maternity units through proactive, funded workforce planning and for significant expansion of midwifery-led and community-based models of care.

We thank the committee for the opportunity to address it. We are delighted to be here with our colleagues and we support the calls they are making. We look forward to any questions the committee may have.

I thank Mr. Fitzpatrick. We move to questions from members.

I thank the witnesses for coming in. I know some aspects of this issue are very difficult to talk about so I appreciate their time.

I noticed healthcare assistants were not mentioned in relation to recruitment.

Regarding workforce planning, do the witnesses see their roles as being pivotal in improving the situation? I acknowledge the staff who work in maternity care in hospitals, such as the healthcare assistants and all the doctors, nurses and midwives. My sister works in a maternity hospital. I do not talk to her much about her job but I know she loves babies and she cares about the parents as do all her colleagues. When she does talk about her job, that is one thing that comes through really strongly. When I read all the notes, I did not see healthcare assistants mentioned and yet they are front-facing staff. They are probably having a huge amount of communication and giving comfort to parents during a time of bereavement. I am interested in understanding where the witnesses see the role of healthcare assistants, the training and where they fit work-force planning? I will fire a couple more questions and then I will stop talking.

Regarding the misinformation circulating on websites of Irish hospitals about which the witnesses spoke, could they expand on that a bit further? If remedied, do they still think it would be a good solution to host helpful information as a digital resource? Have they done research into the training of the midwives and on whether the process could be expedited or done in a more efficient way? How does the investment differ from midwifery-led to non-midwifery-led units? What would it take to expand our midwifery-led units, financially and labour-wise?

I am happy to deal with some of the questions that have been raised there. I will also defer to Ms Dixon who is obviously the midwifery expert. Regarding all our reports, it is very important to say that maternity services are delivered by a multidisciplinary team and every person who is involved in that team is vitally important. It is really important to say this is not about one discipline against the other. Everyone works in collaboration. The Renfrew report in Northern Ireland talks about that and all of the multidisciplinary teams. We speak here today representing nurses and midwives, primarily midwives working within the service, but the work of obstetricians, junior doctors and the maternity care assistants is significant. To address that issue, when we talk about safe staffing, the collaboration is really important. There are two frameworks in existence. There is a framework for safe staffing for medical and surgical wards, and for emergency departments. We welcome that the Government has those strategies and those frameworks. Key to that is the skills mix, whether it is registered nurses working with healthcare assistants in emergency departments or in medical and surgical wards. Our colleagues within SIPTU have also agreed a job description with the HSE around maternity care assistants. They have a vital role to play as well. The Senator should not take it as a slight that the healthcare assistants are not referenced in the notes but we were focusing on our own grades. We make the point that we have a phase 1 and phase 2 framework on safe staffing. There is to be a phase 3 and 3(ii). We welcome that there is a framework on safe staffing because that is vitally important. Later today, I am addressing a WHO Regional Office for Europe conference with regard to safe staffing as well. That is the key. All around the world where they have introduced legislation to underpin safe staffing, it has proven that there are better outcomes for mothers, babies and patients when it comes to nursing. There are also better outcomes in that staff can be retained because they are able to go to work, know they will have a safe workload and are confident in delivering with regard to that. It is a multidisciplinary team. That is vitally important. I will defer to Ms Dixon with regard to midwifery.

We have to leave time for the other witnesses as well. There are just a few minutes left on the clock.

Yes, sorry. I defer to Ms Dixon just on the midwifery-led question if that is okay.

The Senator asked about midwifery training. The midwifery training is under review at the moment with NMBI. New practices and new standards are coming out on that. There will be a place for new technologies in midwifery training and in the provision of midwifery care but it is also about exposure to continuity of midwifery care. We have a highly medicalised maternity service at the moment. Midwives are trained in what they know and what they experience as well but they also work as part of the multidisciplinary team.

I want to come in on the healthcare assistants which the Senator quite rightly mentioned. I reassure her that through the implementation and continuing development of the work around bereavement standards that I have led across the maternity units, we are working with and arranging training and education for all members of staff as part of what we do. Currently, we have some additional funding from NWIHP to develop an online training module which will be specifically for all staff because bereavement care is everybody's business in the maternity services. We would be at the forefront of making sure that is a reality across all our maternity services. I will hand over to Ms Farrell specifically on misinformation.

For full disclosure, I worked for Google for 15 years so I know very well how the Google search results work. We looked at Google searches related to reduced foetal movement and as mentioned our opening statement we saw that half of those searches returned information that was inaccurate or outdated advice. Within that, two of the Irish hospital websites appeared. I point out that a lot of times when information is put up on websites, it may have been put up years ago when we did not have evidence but then it remains there. The two in question were the Rotunda and University Hospital Galway and we contacted them afterwards to remove the content. However, it raises a greater question. We should have one central place for pregnancy information for women that is accurate. First, it is really important that we do not have older, outdated advice out there. Second, it is important for the likes of search engines like Google, or now for AI tools, that they can scrape the correct information from public health resources. We see from the Google search results that Google prioritises information that comes from high-quality credible websites such as the HSE. We see those websites are positioned higher in the Google search result than information from commercial, particularly US, websites, which we found to have a huge amount of inaccurate information. I would ask for central repositories of information and also then a public health lead for information for pregnant women. This person could work across all the different avenues where women receive information. They receive it, for example, in the My Pregnancy booklet. They are not going to have this booklet when they have a problem. They are going to go online and to their phone and they will see information. We need to make sure that information is accurate.

The witnesses are very welcome to the committee this morning. My first question is for the Pregnancy Loss Research Group. It noted that only five actions in the entire maternity strategy explicitly relate to pregnancy loss. Does the group feel the new maternity strategy should have a stand-alone section specifically on pregnancy loss? The witnesses referenced that one in four rated their bereavement care as "poor", which is really sad when people come in and have to deal with a loss. What is the primary issue? Is it the resourcing? Is it the staffing, training, governance or is it just down to funding?

One of the key actions in the maternity strategy was to implement the HSE standards for bereavement care following pregnancy loss and perinatal death, as the HIQA maternity standards subsequently followed up with. There seems to be some impression that this has been done and implemented. Since 2020, there has never been a mention of bereavement standards or of pregnancy loss in the HSE service plan, for example. It is assumed that this is work that has been done whereas as we will all know, this is work that starts and needs to be sustained, to change, to adjust, to scale up and so on. That is one big thing that was in the maternity strategy which has not yet been completed. I would argue that pregnancy loss and baby deaths should cross over into all areas of healthcare, that it should be central to the next maternity strategy and that groups like ourselves and Féileacáin should be at the table in advocating in respect of pregnancy loss and perinatal death. These are not uncommon things that happen in maternity services. Often, women's first or only experience of maternity services is a pregnancy loss, particularly if we look at how common early pregnancy loss is. If we get that right, we do a lot to help people have trust in services and to stay with us for the rest of their healthcare.

I refer specifically to the pieces we have raised that we have discussed briefly in my statement and action plan and that we, together, with the National Perinatal Epidemiology Centre, have developed. The plan exists, and will be published in the next month or two, to prevent baby deaths. That refers to preventing later baby deaths but if we were to have that in the next strategy, that would uplift a lot of things relevant to maternity care experiences and outcomes because it deals with so many other things.

If the Senator looks at risk factors or causes of pregnancy loss or baby deaths, you are going to improve many aspects of how we deliver care and how women experience care. The other areas of need, as the Senator has spoken about, would be around early pregnancy and early pregnancy loss, which is missing from a lot of the frameworks and strategies. It was a feature and is a feature of bereavement standards in our work, and moving into pregnancy after-loss care, what are the models of care for the next pregnancy, for women who have had a pregnancy loss, particularly where that was not a straightforward experience or may have been a traumatic experience? Those pieces should sit very strongly in the next maternity strategy.

This, again, is about all of us working in the health service working together. I think the true forward model of care is not midwife-driven or doctor-driven; it is an integrated model of care with us working together with the people we look after. It is not beyond us to achieve that, and not have siloed working to look after people with needs but where we all have a part to play - all of us working in this area. That would be my answer to how I would write the next maternity strategy. I would love to contribute to it.

In terms of the other care, why is it one in four? They have not repeated the bereavement experience survey that HIQA has. The care experience programme has recently published the second maternity experience survey, which really does not show anything terribly different from five years ago and people seem surprised about that. When it came to the national bereavement experience survey, published in early 2023, we were reassured that there was some good care. Three out of four people had good care. Some even said they had excellent care but we can see within that survey that particular things are being highlighted. There are geographical differences and variations in care with what women experience. We can see that people with late pregnancy loss, maybe because that is what we had focused on a lot in the bereavement standards, had a better experience. People in the second trimester of pregnancy had the worst experience. That survey did not deal with early pregnancy.

The early pregnancy work come largely from our research group in terms of our national programmes of work. Like everything, it is a whole lot of things together, as the Senator mentioned. It is the culture within individual hospitals and the prioritisation that healthcare services and regions put on bereavement care services and sometimes, unfortunately, it is seen as an optional extra and not something that should be prioritised. It should be central to the maternity care experience for every woman and her partner. Unfortunately, it is not. It is about all of those overlapping things. I can talk a little bit more in time about the specific staffing in terms of my knowledge of bereavement staffing, which some of our INMO colleagues may also wish to talk to, but I can specifically talk to issues about those posts, although it is never about just the posts. It is about training, education, culture and resources. The culture of the workforce and the unit we work in are what is key.

My second question is to Féileacáin. Ms Cregan mentioned the inequalities predominantly affecting black, Traveller and Asian women and communities. We have seen this as a massive story a couple of weeks ago in England, where women of colour had suffered great inequalities as they were going through their pregnancy. What targeted measures are needed in this new strategy to address that? We cannot completely disregard that this is happening because it is and we know it is.

The first thing we think in Féileacáin is that we have to measure it. We have to see what is going on. We are hoping to commence more research to see where the inequalities are across pregnancy loss. There should also be an educational piece that is not getting out there. If we do not know who is at risk and if our professionals do not know who is at risk, how can they help the mothers and their families who are coming in? It is an educational piece but it is awareness as well. We are not talking about this. A lot of people would not realise who is at risk of pregnancy loss, especially later pregnancy loss. For me it would be education and the pillars we are looking at for ending preventable baby deaths. It would be looking at education but first measuring it to see how and why. Why are they at greater risk? Is it poverty, exclusion or lack of engagement with the medical services? We must find out why. That is the only answer I can give the Senator. We need to find out why it is happening.

Our services are not structured around everybody and do not meet the needs of everybody. We expect people to come to us in acute or hospital services, and we should be going to them or facilitating arrangements whereby they can get to their care. We expect people to come into our maternity clinics from poorly resourced settings without public transport or from IPAS centres and somehow afford the transport to come into us. We expect people with no English to understand me in a clinic, or me with my phone on Google Translate. We do not structure our resources well enough around people who we know have additional needs.

I thank our witnesses for their presentations and their dedication and commitment in the areas in which they are working. I know it is a very challenging area. I will touch on the first issue. It is referred to in the presentation from the INMO. The caesarean section rate for 2024 was 40.6% compared with 28% in 2012. Is there a particular reason the caesarean section rate has risen so much? What are the advantages and disadvantages of that? For instance, one of the areas I came across during the year was in one hospital, where, for the month of February last year, the caesarean section rate for first-time mothers was 73%. What are the consequences of this? Why has the rate increased so high? I am quoting from the INMO presentation this morning.

To address that, it is a profile of the Western world, where caesarean section rates are increasing-----

Compared with other jurisdictions, where there-----

I talked to a colleague from London recently, where in one particular hospital, the caesarean section rate had gone above 60%. That is a very worrying development. We do see that there is a difference. In domiciliary care, where it is a different profile of patient, caesarean sections are as low as 8% but within the mainstream service, it would be above 30% or 40%. It is a worrying development, particularly for first-time mothers because it means it is likely the following births will be delivered by caesarean section. Ms Dixon will answer that question.

The increases in the caesarean section rate does not happen in isolation; it is also associated with increased rates of intervention throughout pregnancy, to the benefit of some where we have increased monitoring and assessment. Therefore, we can pick up women now who needed a caesarean section who may not have been picked up in the past. There is an element of choice and an element of having repeat caesarean births but there is also-----

Is it not true that compared with, say, 15 years ago, the number of medical consultants in most units, especially in smaller units where consultants were on a 1:2 call roster, now have five consultants? The figure I had of 73% for first-time mothers was in a smaller unit. Should nursing staff plus consultants not be working towards trying to make sure the delivery is carefully managed rather than having to go through the caesarean section?

Absolutely, but the guidance is around induction and the opportunity of women to express their wishes. When I started midwifery 30 years ago, there was a 10% caesarean section rate and a 60% to 70% rate of women who had a previous caesarean section would have had a vaginal birth after that caesarean section. However, that is very different now. Many women are choosing to have a caesarean section subsequently. There is an element of the infrastructure and the intervention that happens throughout the rest of the pregnancy and high induction rates.

I will add to the point around caesarean sections. When we look at numbers, we have to be careful we do not look at them in isolation. One hospital in the UK had a really low caesarean rate. It was highlighted in the UK Parliament and held up as an example of excellent care.

However, what was not measured was the number of babies who were dying. It came out because two women spoke to each other and learned that their babies had died but probably would not have had these women had a C-section. I am not saying that every baby should be delivered by C-section. I just want to highlight the fact that it is not black and white. We need to look at outcomes together and make sure that women have those choices. One of the things we are really missing in women's healthcare is research. If we had more research, we could work out which babies are actually at risk and then send them-----

Following on that issue of more research, there are 19 maternity units around the country. It is my understand that only six are computerised. If the whole system was computerised, would we have more access to more information and could more information be shared? Where are we as regards having a fully computerised system in each of the maternity units? I am not sure who wants to deal with that question.

Progress on electronic health records is something the Deputy should talk to the HSE and the national women and infants health programme about next week. However, the collection of data obviously does not ensure that data is looked at, analysed, reported or acted upon so-----

Are we collecting enough data to be able to carefully-----

Absolutely. We are collecting large amounts of data through multiple different systems with multiple requests for data and multiple users of data. I would argue that much of that is not being joined up coherently in outputs that make sense.

In her presentation, Professor O'Donoghue referred to recommendations not having been implemented. What specific recommendations that were not implemented and which she thinks are crucial is she talking about?

Which report is the Deputy referring to?

In Professor O'Donoghue's presentation, she said that some of the recommendations-----

The Deputy is not asking about caesarean sections now. We are talking about looking at the reports of all the inquiries that have happened across maternity services in the past 15 years. Around five years ago, we published a review of the ten reports that had then been issued. These would have covered Drogheda, Portiuncula, Portlaoise and so on. Synthesising all of those reports together, you can see the commonalities and some of the differences. All of those reports highlight a lack of standardisation among inquiry methods. I refer to the review teams that are chosen, the timeframes and the types of recommendations. There are inherent problems in those reports. In terms of-----

Could there be, in some of those recommendations-----

In terms of recommendations------

Could we set target dates for them to be implemented?

Yes, absolutely. The top recommendation across the ten reports we synthesised for our publication was increased workforce staffing, training or both. The second was comprehensive collection of data on maternity outcomes. The Deputy will know we have a national perinatal epidemiology centre. We report perinatal audits. We report data on babies with very low birth weights, perinatal mortality, therapeutic hypothermia or cooling, and home births. However, we do not have a national caesarean section audit. That might speak to the Deputy's last question. The UK, or certainly England, has done that very effectively. The third most common recommendation across reports is to enhance adverse incident management. The next is to strengthen clinical governance followed by recommendations to improve the transfer of information between staff, to create maternity networks and to have timely and open communication with families. I am sure all of these things sound very familiar to everybody here. That was published four or five years ago.

In the new national maternity strategy, should target dates now be set for meeting the recommendations that have been set out?

Yes, absolutely.

There is no point in making recommendations without setting target dates. That is one of the issues. On recruitment and retention, reference was made to nursing staff. Is there also a challenge in relation to medical staff? I know it is a very challenging area for people to work in. Is there also quite a large turnover of junior doctors? Even in the nursing area, nurses may initially intend to go into maternity care but then drop out after a short enough period of time. Should a lot more support be given to people coming into the maternity area? How can change be effected to provide that support?

It is really important to state that there is an issue with midwife retention. All of the issues that have been raised with regard to what is occurring within the sites themselves need to be addressed. If we do not have the culture that has been talked about, organisational support to ensure adequate resourcing and staffing, and all of these things to strengthen the workforce, we are going to have an issue with attrition. Our members, the midwives working in these 19 maternity units, are saying that retention is now a key issue that needs to be addressed. It would be the same for junior doctors and obstetricians.

The next slot is mine. I will start by continuing with questions on that staffing issue. The statistics in the INMO briefing on recruitment and retention are quite alarming. The midwife headcount has decreased from 1,458 in December 2019 to 1,449 in November 2025 despite the population increasing and an increase in the complexity of care. It is quite concerning that we are not seeing increases in the number of staff there. The number of newly registered midwives was down 34% last year. The largest cohort of practising midwives are now aged 55 to 64. That shows a longer-term issue and the need to recruit and retain people. The INMO survey found that 72% of respondents considered leaving the profession in the previous 12 months, which is another concerning statistic. A number of members of my family work in maternity services so I have some insights into some of the concerns staff have and the challenges they face. Is the lack of investment in the midwifery workforce the biggest obstacle in delivering safer maternity care?

It is definitely one of the obstacles. Again, it is really important that we have a holistic examination of this. The maternity strategy talked about the various models of care and the various pathways for women. There is concern among midwives that, having been trained and educated in the midwifery model, when they go into the units, they cannot operate to the full scope of their practice. We have clinical midwife specialists and advanced midwife practitioners. All the staff within these units want to work coherently but they are continuously inhibited. If you had six buses that have to go out from a bus terminal this morning, you would have six drivers to drive them. However, if there was supposed to be six midwives to deliver care on a maternity and delivery unit on a particular morning, there might actually be three. If it was a bus depot, the buses could not be driven so the buses would not leave. In the maternity services, mothers have expectations with regard to the safe delivery of their babies and these expectations are not being met because of workforce issues. The HSE talks about an increase of thousands within services but the reality is that, if you look at the microdata, there has been no discernible increase in midwifery on in public health nursing, which supports the antenatal stage through the checks that need to be done on children. There are significant cultural issues and organisational issues as regards support for mothers. A lot of work needs to be done there.

I will make a final point. The Renfrew report in Northern Ireland provides a good model. It talks about strengthening the workforce and fostering a culture of respect, support and shared learning across the professional groups. It also talks about addressing shortages and investing in the education, training and retention of midwives and other colleagues.

Reference was made to the target midwife to birth ratio of 1:29.5. Is that being met in any of our hospitals?

It is being met in some of the 19 units but, alarmingly, the ratio in some of those units was 1:80 12 months ago. The statistics in that regard are alarming.

In what hospitals was that ratio seen?

That was in Mullingar hospital. The statistics have improved since then but the issue is that this was the target ten years ago. The national women and infants health programme and others then talked about getting to a ratio of 1:35 but that was not met either. This is why we talk about legislating for safe staffing. It needs to be enforced. It is very important. Outcomes are much better when units are staffed safely.

I will move onto some of the other witnesses. If we have additional time, we will come back to the staffing issue. I will move onto ending preventable baby deaths. Professor O'Donoghue mentioned this and Féileacáin mentioned the work that has gone into the action plan. It is an area we could potentially have a hearing on once that plan is published so that we can consider it in more detail. It is a really important issue. The bereavement standards are really important but, if there are things that can be done to prevent baby deaths, it is crucially important that we do them. If the committee or the Oireachtas can help to get some of that information out and to create awareness, that could have a significant impact. I was really struck by the statistic in Féileacáin's opening statement that the number of stillbirths and babies who die within the first 28 days is greater than the number of people who die tragically on our roads.

That is probably not known in terms of the scale of it. We do have huge levels of awareness campaigns on road safety and things we can do to improve road safety, but we are not necessarily hearing that in terms of preventable baby deaths. Why does Professor O'Donoghue think it has not been prioritised to date? Why has there not been a focus on this issue?

Several people have already said today that this is challenging and difficult. It is certainly far more difficult to experience it than it is to talk about. Unfortunately, all aspects of pregnancy loss have been quite a stigmatised and hidden issue which people do not talk about, and if we do not talk about it, it does not exist and it does not get prioritised. That has certainly held us back. There has also been a fear that if we talk about pregnancy loss in pregnancy, we are going to upset women or cause distress. We know from our research that is not the case and that if that is done in a sensitive, informed manner by healthcare professionals who people trust and are working with in a scenario of continuity of care, women value receiving correct information, and, as we talked about earlier, having places to go where that information is accurate and correct. That can be done much better.

It is also commonly framed as being something that is rare and unusual, and that our rates are better than those of other countries. Like many things, we are sort of in the middle of countries in Europe. We are certainly not leading. Unlike many other high-income countries, we appear not to have joined the dots to realise that we could actually prevent many of the deaths that do occur, although not all. Pregnancy loss in all of its forms is, unfortunately, not rare. It is not even uncommon. It does happen to many people, particularly if we look at earlier types of pregnancy loss. Even when we look at stillbirth, that will still happen in around 1 in 200 pregnancies in our current numbers. We would like as a group, certainly, and feel that we have both sufficient experience and information from the research we have done to move beyond, obviously, the importance of caring for people who have a pregnancy loss to looking at how we can join this up to look to prevent baby deaths.

I would just like to add to what Professor O'Donoghue said. Where we have done amazing work is with sudden infant death syndrome, SIDS, or cot death. Going back to my booklet, there are four pages in here talking about how we can help reduce the risk of cot death. That is a really horrible conversation to have with a woman during pregnancy and yet doctors have that difficult conversation and the result is a huge reduction in the deaths over a number of years. Today, in Ireland, stillbirth is actually ten times more common than cot death. However, when we go through this booklet it will hardly be mentioned - very rarely - and yet we have four pages on cot death, which we do so well. The women of Ireland deserve this to be brought out of the shadows and to be spoken about so that they know that every pregnancy is at risk of a stillbirth over neonatal death, but there are things we can do to prevent it. I think that would help. Then, for those deaths we cannot prevent, we could improve the care for those families. For Féileacáin, we would like to prevent people walking in our shoes and then make sure that everyone has the right care if their baby does die.

Ms Farrell might just reference the booklet for the record.

Of course. It is the My Pregnancy booklet that is provided in pregnancy.

By talking about it, we reduce the shame. There is a feeling of stigma, if people do speak about baby death when someone is pregnant, about frightening women. I would much prefer to have been frightened and now have my 20-year-old daughter - I am sure Anne-Marie would feel the same - and been educated about what reduced foetal movement, or changed foetal movement in my case, meant instead of being told what I was told and rocking up a few days or hours later with a deceased infant. It is how it is done, as Professor O'Donoghue said.

I thank the witnesses very much. I thank Ms Cregan for sharing that as well.

I thank the INMO, Féileacáin and the Pregnancy Loss Research Group. In particular, we have had a lot of dealings with Féileacáin and the Pregnancy Loss Research Group over quite a number of years now. I want to pay tribute to the incredible work they have been doing to, effectively, lift pregnancy loss out of the silence that has surrounded it for so many years. There has been positive change over the last number of years. Obviously, there is an awful lot more that has to be done. However, I pay tribute to the work and, of course, to the INMO in terms of its work in representing midwives and nurses.

I want to make a comment first. There has been a lot said today about resourcing, and it is really critical. We do need safe staffing legislation. I have a particular concern. It is a stark figure in terms of the reduction in the number of midwives between 2019 and 2025. However, when I look at the population, obviously, the number of births has fallen by about 14,000 over the last decade and it is set to further decline. With the HSE now moving to a population-based resource allocation model, I have a real fear for maternity services because, obviously, if there are less babies being born then there are going to be less resources going into maternity services. There are lots of resources needed in other areas, but we need resources into maternity services. I would, therefore, be interested to hear from the witnesses. Obviously, population-based resource allocation is quite a crude model, but I would like to hear from them on the complexity of care.

The second comment I want to make, although I have lots of questions, is on the implementation. We have lots of great things in the current national maternity strategy. We have great guidelines under the national women and infants health programme, NWIHP. Obviously, we need a lot more, but the implementation is the big piece. If anything could come out of this hearing today, it is the implementation piece and how as an Oireachtas we ensure that happens into the future. I would like to hear more from the witnesses on the complexity of care piece as to how we make that argument in terms of ring-fencing existing resources, because that is going to be the direction of travel here, so that there is better care into the future in maternity services.

I will go to the INMO first.

We have to acknowledge that the acuity of women has changed. Even when a TD was talking about the increased Caesarian birth rate, a lot more care needs to be provided to women who have Caesarian sections than to women who have a straightforward vaginal birth and leave the hospital a day later. Also, our population has changed. The diversity of our population has changed. As the Deputy said before, we need to be going out to women now rather than expecting women to come in to us. We need to meet them where they are at. When we talk about the feedback service, we know women of minority groups, such as the Roma and Traveller populations, are not represented in the feedback, so their experience is not. We have an epidemic of intervention in labour and we also have an epidemic of birth trauma that affects over 30% of women, including women who have had pregnancy loss or are experiencing birth trauma, and 6% are experiencing post-traumatic stress disorder, PTSD.

With regard to recruitment and retention, it is not that midwives want to work in a silo as opposed to with obstetricians. We all provide care as a team and we need to meet women where they are at but we do know where there are pockets either in the HSE home birth service or in continuity of care models where we have much greater rates of retention. We keep staff in those areas better. In the fragmented models of care, midwives move in and move out and move on. However, that is not the experience when we provide continuity of care to women, and continuity of midwifery care is also evidenced to reduce the rate of miscarriage, second trimester loss and stillbirth. It is easier to have those conversations on foetal movements and what is normal and to have somebody at the end of a phone. We do know that women who are not native Irish women go to their own local resources to get information. They go to their Polish website to get the information. In some ways, us improving the information in the HSE will meet the needs of some women, but it will not meet the needs of all women.

Okay. I thank Ms Dixon.

I am going to speak on the implementation issues. We can give some examples. In terms of the maternity strategy and the bereavement standards, the thing around bereavement is that we have implemented the bereavement standards, but we do not look to what extent we have implemented the different actions within it across the country. We know from the HIQA care experience and our own work that service provision varies around the country, and it is borne out in people's experiences as well. Professor O'Donoghue alluded in the introduction to the clinical midwife specialist in bereavement and loss. When we speak about the standards, we now have a bereavement specialist in each of the units. Our job is kind of done. It speaks to the issue that it is everyone's job. We know when we look at the figures, however, and Professor O'Donoghue has the specifics on it, that there are two units in the country where there is no bereavement midwife in post. There are other units where there is not even one whole-time equivalent because people are moved into other areas. We saw that a lot in our evaluation of recurrent miscarriage services. It is that deprioritisation of pregnancy loss and bereavement care where it is like people say it does not matter, we can move them into another part because maybe that is not important, and they are needed somewhere else.

Ms Farrell in the Féileacáin submission spoke about guideline implementation. We are producing guidelines, often on very little resource and with people doing it in their spare time.

We really need to invest in implementing things. It is like generating actions and targets. We need to follow that and we need to resource it. We need to go back and measure to see if it is happening and, if it is not, ask why. I think there is learning individually within units and also across regions and nationally to see what the patterns are and if there are structural things at a higher level where we need to resource all units or whether there are particular issues in specific units as well. There are issues in respect of perinatal pathology services as well, which are really patchy around the country. That has a lot of knock-on issues as well, which Professor O'Donoghue and Féileacáin might be able to speak to.

Picking up on the bereavement midwife specialist role, a key anchor of the funding of implementation of the bereavement standards in 2016 and 2017 was to make sure that every unit had a least one WTE and subsequently the NWIHP funded a couple of uplifts in numbers across some of the bigger units. Across the 19 maternity hospitals, we know there are still problems with sustaining those posts and that obviously speaks to prioritisation of advertisement and recruitment. It speaks to turnover in some units, particularly around Covid-19. It speaks to the staff retention discussion, and it also speaks to the fact that while that person can be a linchpin and an absolute driver of improvements, they cannot work on their own. They must have other members of the healthcare team to work with them and support them. There are two units where those posts are currently vacant. There are two units where there is a significant amount of redeployment and there are two units where the posts are only half-filled currently and are filled in other areas. Again, this is something that we report on through the national women and infants health programme, but, again, it speaks to the fact that, yes, one staff member cannot do everything, but if that was the only thing that people think was a success for bereavement standards and it is the only thing that I see measured in reports from the Department or the HSE, that is still not sustained.

I will not be around for a second slot because I have to go into the Chamber, but I have two questions that I want to throw in and perhaps the witnesses could respond. The first question is about perinatal mental health inpatient beds. My understanding is that we do not have them in the country. The national maternity strategy talks about the importance of looking after women when they are experiencing perinatal mental health issues and about the importance of bonding between mothers and babies, but they are doing so from a distance if a woman has to be hospitalised. I want to hear the witnesses' views on that. The second is about home births. We are told that new national clinical guidelines are to be published soon. There was the suspension of the service in the mid-west last year. I want to hear the witnesses' views as to what should happen regarding home births because there is a lot of alarm on the part of those who want home births, but obviously we need to get the guidelines first.

I thank the Deputy. We will hold those questions and if we have time at the end, we will address them and have them on the record.

I thank the witnesses for coming here today. I particularly commend the INMO on its advocacy and its campaigning. I understand from attending both the disability matters committee and the health committee's hearings that the advocacy of the INMO, the Irish Medical Organisation and Irish Hospital Consultants Association is so important because they are advocating not just for their members, but for all of our citizens. I really appreciate that. I also thank my colleagues from Cork. I believe I will be meeting them in a couple of weeks' time and I look forward to that. I thank them for their work on this.

As a society and a political community, we understand the value of research in the natural sciences and technology, but the research we do in the human and life sciences is so important. Successive Governments have spent billions of euro on judge-led inquiries into this, that and the other, and yet we have this incredible resource that is investigating areas that are of such importance. They are contributing to our knowledge and serving the public good. I thank them for that.

Before I talk to Féileacáin, I commend my colleague Senator Nicole Ryan from Sinn Féin for setting up the pregnancy loss and maternity bereavement group within the Houses of the Oireachtas. It is great to be on that and to share the energy of the cross-party participation there.

In terms of Féileacáin, I thank it for the work that it does. Ms Cregan mentioned the importance of telling the story to destigmatise loss. We had five pregnancies, all in the Coombe, 20 years ago. It is such a dynamic place. I am a Dubliner and I always enjoyed going outside and seeing all of the pregnant ladies walking up and down smoking their cigarettes. They would ask how you were getting on. In one of those pregnancies, we lost a little girl, Liadain, to a cord accident at full term. I was at all of the deliveries and the others were noisy affairs. During my first experience, I remember naively asking the midwives why they were wearing white wellington boots and they all laughed. That loss was a silent delivery. It was so extraordinary to be there during what was such a silent delivery and then to hold my little girl, my daughter. This was 23 years ago, and I cannot speak highly enough of the midwives. I had brought a babygrow, thinking that I could dress her in it, but she was so small. The midwives had a little piece of curtain material which they fashioned into a little dress for her and they had a little safety pin. She looked beautiful.

They also had something that I would never have thought of. They had an Instamatic camera and we got to take pictures of our little girl. We would not have thought of that or been able to do that and we have those photos to this day. It is extraordinary. She is so like her siblings. The midwives told me to spend as much time as I liked with our little girl. They gave us a little cardboard box to put her into and some towels to cover her with. We then brought her to the nurses' station because it was a very busy ward. There were expecting women going into contractions and you were carrying your little girl there. What struck me was the kindness of the midwives but when I came to the nurses' station with our little girl, I was not the only one. Ms Farrell spoke about the prevalence of this and how it is 10 times more common than cot death. I think of my daughter all the time. It has a huge impact and it should have because it is a life.

I thank the Chair for allowing me to speak for so long, but it is important that we put it on the public record because this experience is so common. The women in the Coombe were amazing, but I suspect it was an informal, in-house, ad hoc set of arrangements. Does the national maternity strategy sufficiently address putting in place proper standards and codes? I heard Deputy Cairns, the leader of the Social Democrats, say that when she was in the maternity unit women were afraid to lean back because they would lean onto an incubator. This is not any criticism of the wonderful staff, but are our maternity units safe? Have the members of the Pregnancy Loss Research Group done a comparative analysis with any other setting where it is being done right or better? I address that question to all of the witnesses. Is there a jurisdiction or a health setting that does this well?

There are a multitude of questions there. Obviously, we commiserate with Senator Clonan. I have three children as well. In the midwifery-led unit in Cavan General Hospital one of them needed an intervention because he was a bit laid back in his delivery and he continues to be laid back now. This is such a big event for mothers and fathers. It is really important that it gets the priority it deserves. From our point of view, we have a strategy that is now ten years old.

There is a lot to be done to implement the strategy as we go into a new strategy. However, the key is delivery. I am sorry; I did not mean to use that pun. The key is whether we have the staff in place to provide safe, high-quality care. The answer is that we do not because we have not met the targets in the guidelines or the strategy. There are people working hard, including obstetricians and midwives, to try to deliver safe and quality care, but we are asking for them to be given a little help. We have the research. It should be followed through on. We do not have the resources, but if the front-line practitioners, whether they are doctors, midwives or anyone else, are given the resources, they will deliver. They are trying to deliver in the very difficult environment that exists now. There is a lot more to be done in this area. It is time we spoke out about pregnancy loss and the experiences of women. The veil needs to be lifted to a certain extent. We are very much back in the 1950s in some places with regard to models of care.

I might just let the other witnesses in.

I apologise.

We have standards, including bereavement standards and HIQA maternity standards, for safer and better healthcare. We do not need any more documents. We need to get on with reading the documents and enacting or implementing them and we need to hold people to account for failure to implement, if that is what is happening. We need to resource implementation as well.

I have been in every one of the 19 maternity units in my role in implementing bereavement standards, as have my colleagues in the INMO. I always say to my colleagues that the most educational thing they can do is to go to see where everyone else is working. As a Dub, I am fortunate to work in Cork University Maternity Hospital, CUMH, which is still the newest maternity hospital. It opened in 2007. We are co-located with an enormous general hospital and paediatric unit and we are lucky to have space and facilities available to us, but it was an absolute education for me to visit all the other maternity units and see how staff invested in maternity services absolutely try to make the best of the old facilities they have. It was also an education to see across some of our hospital sites how other areas of the hospital have been enormously resourced, made look beautiful and given new facilities while the maternity wing or labour ward has not.

As part of our work with bereavement standards, we have published a lot on spaces and places to show examples of good practice to people and give people ideas about how they can make the best of those spaces. There is no doubt that some of our hospitals struggle with facilities, but for the majority of those who use the services, it is about the people using those spaces. No matter how bad the space is, if the care experience is good, the space is not as much of an issue, if that makes sense.

Safety is a different thing for a woman than it may be for a midwife or an obstetrician. There is physical safety and psychological safety. It is about safe staffing. We have a lot of evidence. It is about implementing the recommendations from that evidence, consistency and infrastructure. The infrastructure influences how women experience the maternity service, but it is also about how we can work within the service, particularly as infrastructure plays a role in safety, in getting equipment in and out and in getting women in and out.

I thank the Chair for the time. It is appreciated.

I suggest that we take a break for five minutes. Is that agreed? Agreed.

We will continue our consideration of the National Maternity Strategy 2016-2026, including progress on its implementation. Next is Deputy Daly.

I thank Professor O'Donoghue and her colleague and the representatives from Féileacáin and the INMO for coming in. It is timely that we are discussing this subject. I agree with the witnesses. Almost every family, including my own, has been touched by infant bereavement. We had four very healthy children. My wife then had an early miscarriage. I did not understand bereavement fully until that happened to us. It took a while to get over it despite the fact that we already had four very healthy children. As a GP, I see it, but I do not think I fully understood it until I had my own experience.

We talked about education, training, culture, physical infrastructure and human resources. I really regret - I cannot allow the opportunity to pass - that planning permission for the additional facility in the Rotunda Hospital was turned down. It is a piece of national infrastructure for women, but it is not just for women, it is also for their children and partners. It is extremely regrettable that this happened. I have worked in hospitals. It is a while since I worked in a maternity hospital, but I often thought maternity units were the worst infrastructure in the whole hospital. They were Dickensian in my time. It was actually shocking to see. The situation has improved, thankfully, but it has not improved enough. I looked at the national survey there. We are standing over satisfaction ratings of 70% to 80%. This means that, on average, 25% of women are unhappy with the physical infrastructure in which they are giving birth. The service they are getting is simply not good enough.

Moving on to education, I will probably put this question to Professor O'Donoghue. In regard to reducing perinatal mortality, are we in agreement that the risks are easily identifiable and that we can target them? I read an Irish Medical Journal review of the perinatal mortality rate in Ireland. I will be very careful; I do not want to gaslight women and use phrases like "because you smoke", "because you drink" or "because you may be overweight", but are we clear on the risks? Are we clear that we can reduce them?

We are. We have a lot of information on the numbers of later pregnancy losses that happen. We do not count pregnancy loss under the registerable number but if we look at pregnancy loss post 23 weeks, we have a lot of information. We are one of four countries in the world that has a national perinatal mortality audit. We know our numbers. We know the causes as they are reported and we know a certain amount about the pregnancies and the women involved. We do not have a further review or structured, systematic or standardised review processes into baby deaths from which could come better learnings. We have good knowledge from this country and other similar countries around what the risk factors are but, unfortunately, sometimes there are many overlapping and complex risk factors that come together in a pregnancy to cause that particular outcome. There are many deaths that occur in a so-called normal or low-risk pregnancy. That is why there is not just one approach or a simple fix to this. If you simply design your prevention of baby deaths around a smoking cessation strategy that is not really going to change things. That is partly why we have been working together on an action plan that combines a couple of different areas. While it is focused on baby deaths, it would improve other things such as pre-term birth or other aspects of the care experience. We are looking at public awareness and education, at how we talk about risk in pregnancy with women and at how we have those conversations routinely.

I am always on the clock here. That is where I come to access. I am speaking to everyone here. We have talked about identifiable inequalities for black, Irish Traveller and Asian communities. We know there is an international dimension to that as well in terms of risks that women have. On getting access, we can have the most sophisticated units based in cities that are removed from women who have poor resources, lack of access and maybe inadequate education or advice. Are we reaching out to communities to provide those? I am of the view that is where we should start.

No. I spoke earlier to that, and we can come back to others. I do not really see that happening for the particular groups we are talking about. There are improvements in community care and there are some external antenatal clinics that are remote from the hospitals, but not enough. I would argue that is not really going to the places where most of those women with needs lie. Like everything, there are lots of different ways we could - and we need to do so - to reach people in different languages and formats or on different channels of media. No, I do not think we are bringing the specialist expertise. There is more we could do on the community midwifery side. That is a given, but I do not think we are bringing the specialist expertise to where the people are. I am sorry, I will hand over to colleagues.

We are not working enough with communities to design better services, and that is on the health system. It is interesting that we are talking a lot about the maternity strategy, but there are lots of other Government strategies, like the Traveller health strategy and the mental health strategy, that could feed into some of these issues. When you look at the recommendations within all of those you can adapt them to pregnancy loss and achieve outcomes that way. One of the things I would be interested in is a more joined-up, all-of-government approach to looking at issues like this. It is like the case of health in all policies. There should be a maternity and pregnancy loss angle to every policy we have, be it poverty or climate change, when you look at the bigger picture. It is really important to consider those things because that is how we will effect change.

There are lots of ways women can access maternity services, in particular if they need to access them early, because we know women who do not access the service early. I refer to access to GPs. The latter are not the only people who can refer women to the hospital. They can be linked with somebody else with whom they can self-direct, where they can refer themselves, if they find themselves early and have delayed access to a GP. There are now even things around access to aspirin early pregnancy. There are lots of areas where we end up maybe looking after women too late.

That is the point. We could have community midwife services possibly working in conjunction with GPs, but I do not see that on the ground-----

There is also more we can do around early pregnancy units because every hospital has one and we have had almost no developments or improvements, with little exception, since some money was put into that in 2010. I refer to women who access early pregnancy units, which is quite a lot. Almost 4,000 women accessed our early pregnancy unit in Cork last year. That is an opportunity for people to be signposted to all of the various support services and midwifery or medical services they might need in pregnancy and there is a lot more work we could do there. Those would be obvious avenues into the services.

We are going to be looking at the mother and infant scheme, so that is probably something for when we are revisiting that too.

I am short of time, but I have two observations to offer.

When women are in the early pregnancy unit, they are sent out and have to be re-referred into an antenatal unit. What a waste of time and paper.

Coming specifically to Portiuncula, when we talk about networking, the whole breakdown in the governance network between UHG and Portiuncula maternity unit has still not been satisfactorily answered by HSE west and north west. Do the witnesses have any comment on that?

I do not speak for the service, but there are issues around that which have not been resolved. As the Deputy said, there is a lack of clarity and transparency.

I find it absolutely extraordinary that the REO could say here that because things were not working out as planned under Walker, we dissolved the relationship. That is simply unacceptable and extraordinary. That is not a comment against the witnesses; it is an observation.

We fully agree with what the Deputy has said. We saw the appearance of the HSE before the committee. We are gravely unhappy with how things have been handled by the HSE as regards Portiuncula. That is why we have referenced the regional units. There are 19 maternity units. When you look at all of those that operate in isolation, whether it is Mullingar or Portlaoise, etc., there is much work needed in that regard. We are grossly unhappy about how those things have been handled.

I thank our guests for their time, experience and expertise. Ms Dixon spoke at length earlier about the staffing issues being faced there. I want to look at this from a slightly different perspective for a moment, if we can. For a professional nurse who is working with a mum and dad who have experienced a stillbirth, are there any kind of supports available for the staff member? I can only picture myself working in that role and can see myself bringing that emotional distress home with me. If that is something I am seeing repeatedly, depending on where I am working, that is going to take a toll on me as a person. Are there any supports available for the staff?

Much of that depends on the context, such as whether it was unexpected or how it happened. On the one hand, there is the review process with regard to what has happened and a look at the care. There is, of course, concern within that as to whether there was blame or failings in care, which will traumatise. We have much evidence now around the second victim and the staff who care for these women who have experienced loss or any other trauma.

On the other side of that, there are the HSE's own services, such as the after action reviews, the employment assistance scheme and access to counselling and psychological support that is there for staff.

How often is that taken up by staff members?

Maybe 18 months or two years ago, we did a review of what supports were available to staff in the 19 maternity units. Like everything, it was very varied around the country as regards what was provided. Bereavement midwives themselves should be entitled to clinical supervision. Whether they can access that or not varies around the country in terms of being given the time or whether it is available.

The HSE supports are available, but we often hear that things like employee assistance programmes are very hard to get time to avail of. There are some dedicated programmes, like Schwartz programmes or trauma risk incident management, that are also available in the South/South West Hospital Group. However, the provision is patchy and it is about getting staff to take up the programmes so they can be available. They are often not advertised or staff cannot get relieved to take them.

The short answer is that there are not adequate supports in place for front-line staff-----

That is what I thought it was going to be.

-----in multiple scenarios on this. A lot of work needs to be done with regard to access to occupational health or access to these employee assistance programmes, and not enough is available to support staff. That is coming out very strongly in our surveys.

In maternity, we would see that programmes such as EAP are not considered sufficient for many staff. Because of the unique nature of some of the outcomes that happen in maternity services, as well as the incidents and aftermath for the people involved and the staff, we need more maternity-specific solutions and supports.

Is the patchiness that Dr. Hennessy described a combination of the supports simply not existing or a combination of a geographic divide? What are the contributing factors to that?

It is a combination of all of that. It is about what is prioritised in the unit and within the health service. Midwives and obstetricians are expected to come back in the next day and start all over again. If things move along, relieving people to access those services will acknowledge that this experience is valid for the person.

Unfortunately, something that is relatively recent is the recognition that the staff involved are also sometimes being traumatised by a particular event that happens, or even as part of their normal work, which is actually quite hard to deal with. Therefore, the support structures have not been recognised as needing to be in place. However, we have had the evidence for many years now that this is necessary, and we have some good examples around the country, just as we have examples of a lack of provision.

It goes back to the point made earlier as regards needing national standards for this.

And implementation.

We may be breaking up into regions now, and there is a big focus on the regions, but we need national guidance standards that clearly say what should happen in this regard.

What we are looking for there with bereavement standards is the staff. It is all there. Rewriting those standards will just update what is already there.

If I could just move on, I am conscious of time. I am glad Mr. Fitzpatrick mentioned regions, and he also mentioned Mullingar hospital earlier. I am a mum of four, and one of them was born in Mullingar. It is my local hospital. Mr. Fitzpatrick mentioned Mullingar in the context of improvements. Will he give us some more information on that?

There have been some improvements in staffing within that service. We talk about the strategy of one midwife to 29.5, but at one point in time, Mullingar was operating at 1:80, which is way too high. Once you have that inadequate staffing, many other things happen there as well. How is it possible to deliver safe care if you do not have sufficient staff to do that and if you are way below what it should be?

It goes back to the point that there are midwives and nurses working in other jurisdictions who may consider coming home. The HSE has a really good programme where it will support those people to relocate to Ireland, but nobody knows about it. It is nearly like a secret.

Peculiarly, I asked a parliamentary question on this several weeks ago. The response I got back, and I am being generous when I say this, was a word soup. There was not a single figure on the entire page that could tell me how many staff had returned home under that scheme.

To add to the point on the unit the Deputy mentioned, the specialist post in bereavement and loss for midwifery is currently unfilled and vacant. That is because the person retired, and there was a successful recruitment into that post, but that person remains to be released from their job because whatever post they are coming from has not been backfilled. There is currently no specialist midwife in bereavement and loss. That is just a point of information.

A broader point on that is that the pay and numbers strategy, as the HSE calls it, is impeding. Now, a director of midwifery within a unit says, "Mary has just retired. I need a midwife to maintain my staffing levels, etc." She has to go through an arduous process that will take months to get approval to fill that post. The HSE wants directors of midwifery to have all the responsibility but no authority, because staffing is so closely linked to the health and well-being of the mothers and babies coming into that unit. It is a farcical situation that a director of midwifery, a senior manager within the HSE who knows the service better than anyone else, has to go through an arduous regional process and through several layers of management within the HSE to get approval to fill a post. It is ludicrous.

My final question is for Féileacáin. What do the witnesses want this committee to take away from today's engagement, and what do they want us to make a priority from the organisation's perspective when we engage with the Department and HSE?

It would be to engage with the ending of preventable baby deaths, because there is so much we can do.

There is also the full implementation of the bereavement standards. We have many things published on paper, but it is about how they will actually work on the front line for bereaved families.

It is from the glossy brochure to the actual delivery in situ.

Yes, it is twofold.

It is also probably for the people who work in and experience the services.

We can do it, and we know we can. We know our babies might have lived with different interventions, and my grandson might not have, but that is what we would look for in order that other families will not have to walk this path.

Going back to the Deputy's last question on supports, we get many midwives ringing us regularly for support. I believe they are being referred by the bereavement midwife on their team, and while they are always very upset, sometimes it is for reassurance.

We cannot give any clinical support, but what we can give is support around how they manage working with the mother, the care and the-----

The human interaction.

Yes, the human. We talked about this earlier. I will remember the midwife who worked with me for the rest of my life. I will remember the midwives who worked with my daughter when her baby died in the neonatal unit, and the nurses there. It was said that culture eats policy for breakfast but the culture of care, compassion and honouring your baby will impact on the trajectory of your grief. It will impact on how you manage the journeys for the years ahead. We heard another Deputy talk about that and how, after 23 years, the child is such a rich part of their life. It is so the support is there. Féileacáin supports anyone affected by the death of a baby. That will include midwives, but there should be a lot more available to them because it is an horrendous experience for them.

I too welcome our guests. Similar to my colleague Deputy Daly, I will raise the Rotunda Hospital planning decision by An Coimisiún Pleanála in regard to refusing 80 new rooms and a new operating theatre. It beggars belief. We have all seen the crowded conditions there, the environment that staff are working in and the possibility of infection spreading among babies. That needs to be addressed as a matter of extreme urgency. It is a real health and safety issue.

Moving closer to home, I wish to raise University Hospital Kerry, UHK, and the maternity unit there, the location of which is at a distance from the surgical theatre. I received a number of complaints in regard to the safety of mothers and babies. I was previously informed by the general manager there that it is at reappraisal stage. I acknowledge the work of the hospital manager and all the staff in UHK. They are doing a great job there. I understand that UHK now has a dedicated lift for obstetrics and emergency cases. That obviously has to be welcomed. We need a new maternity unit in Kerry. It needs to be provided much closer to the operating theatre. It is important that I raise that at this meeting. As I mentioned, health and safety is absolutely critical. This is important for expectant mothers and their families, hospital staff and the entire hospital community. I know this is not the witnesses' call, but a new maternity unit in University Hospital Kerry has to be a priority.

With regard to infrastructure, which was referenced with regard to the Rotunda, there is an issue our colleagues have highlighted. If people want to work in an environment that is conducive to delivery of safe, quality care, there certainly are significant deficits with regard to the infrastructure that exists. The other issue we talked about was the Caesarean section rate and how high that is. It is important, particularly in the out-of-hours period where a Caesarean section is required for an appropriate intervention that is required, that the service is available. There is an issue across the 19 sites, of which Kerry is one, and that is the number of staff who are actually on call to the theatre-on-call service out of hours. There is a severe problem with staffing within theatre services at the moment. A lot of staff are doing excessive hours on call to try to maintain the services.

There is an issue in maternity services that needs to be looked at, which was brought up at the Lourdes inquiry as well. At that time, a separate on-call team was put on to deal with maternal emergencies. What we now have are hospitals that have emergency departments that have maternity units that then call on the theatre service. A second team needs to be in place, in case there is an adverse event outside of the normal core hours, in order to respond to that. Kerry is one example. It has one on-call team but that is not sufficient to deal with the general surgical emergencies and obstetric emergencies that may arise as well. I wanted to make that point in the general sense with regard to the infrastructure that exists. I do not know whether there are other comments to make in reply to Deputy Daly.

I do not think it would be appropriate for me to speak to UHK specifically on matters of its infrastructure, unfortunately.

I have an open question for everybody. On funding for bereavement midwives, in particular, and across the board, the Department ring-fenced some funding for research in endometriosis and postnatal care. Pregnancy loss was not put into that space, but it was mentioned that losses, miscarriages and ectopic pregnancies do not happen nine to five on Monday to Friday. My miscarriage happened on a Sunday morning. I had to go back home and go back in the following Monday morning to get it confirmed. Mentally, I was there by myself at home and I knew what was happening. It is a very traumatic period, in the first instance, when you are told a miscarriage is suspected. You know you are having a miscarriage, but you are then sent back home and have to wait until somebody comes in at 9 o'clock on Monday morning to get it confirmed. Should there be ring-fenced funding for posts like this, which are around the clock, for women who suffer losses?

There is a lot more we can do. We talked a bit about simply one role, that of the clinical midwife specialist, but that is just one person and the greater majority of pregnancy loss that, for example, is early pregnancy loss does not have a specific specialist service and often cannot fall within the remit of those midwives who are very busy looking after the later pregnancy losses. It was part of the maternity strategy that all women should have access to well-resourced early pregnancy assessment units. I mentioned that there has been almost no investment in those units since the original investment was put into making sure they were established across all units in 2010. There is a bigger piece of work we need to do around the services needed in early pregnancy and pregnancy after loss.

The Senator mentioned research. It is admirable that more research funding has been directed towards overarching women's health but there has not been, in the last couple of years, funding either for the Department of Health's evidence for policy programme or for the HSE's recent women's health call, or any specific prioritisation across any of the research funding bodies. Pregnancy loss and perinatal death have never been a priority. This is in spite of evidence from research, such as HIQA's report into early pregnancy loss and the Health Research Board, HRB, evidence review on research recently, and the fact there are knowledge gaps and needs.

Specifically around early pregnancy, there is a lot more we could do. Our early pregnancy units need to be open for more hours. We also need to have a pathway of care for people who present to the emergency rooms or assessment areas in our maternity services, some of which are resourced reasonably well in having a separate space but most of which are not. People are coming into a general assessment area with many other women both in advanced pregnancy and other women. It is not beyond the wit of our health service to resolve that and to make sure there is an uplift in early pregnancy care. I certainly think that is very necessary.

Definitely. Looking at the Department of Health's statement of strategy, one of the enablers for it is embedded research and innovation. It is such a privilege to work in a group like ours where we are embedded within the maternity services. We are driving research that is very much based on what is needed locally, regionally and nationally. We can do research that is a priority but we can also implement measures. For example, the advanced midwife practitioner role in miscarriage and early pregnancy loss is being piloted in four or five-----

We have five posts. We have two AMP posts, one of whom has started in Cork.

That will be the first in the country.

That is in different units around the country. That comes from the Health Research Board funded project we did on evaluating recurrent miscarriage services. It is to be in a position where that type of research can be done but also followed through so it is not wasted and drives needs. If a role has been evaluated and it works, we can make the case to scale it up. That is one thing to take away - how we can drive evidence-informed care and meet people's needs, speaking to the fact that we do not need to keep asking bereaved parents or people who have experienced loss about their experiences unless we actually do it. We can talk, create strategies, targets and action plans but we need to follow through, be transparent in what we do, report back to people and admit when things go wrong, and we need to change things. When things are going right, we need to do more of it, sustain it and scale it up nationally. The onus is on us all to follow that through.

On training for dealing with bereavement, it is important we have bereavement midwives in place for all types of pregnancy loss, whether early, later or neonatal deaths, but other staff members are going to interact with bereaved parents. It is about making sure all staff have some level of bereavement training. Maybe someone is going to talk to their GP a year or two later and they still want their loss acknowledged and to be cared for in a compassionate way, or perhaps someone has to return to hospital because they had a complication after giving birth. These things happen to people who have live births and those who have lost a child. They still want their loss acknowledged. They will have to be dealt with slightly differently from someone who delivered a live baby. It is important, even if someone is not a bereavement midwife, that they can still deliver compassionate care no matter when a baby died.

We concur with those sentiments. It is really important those bereavement CMS posts are in place. Some of those posts are filled, but in Portiuncula, that individual is on maternity leave at the moment and the HSE thinks it is okay and will not backfill that post. That could be left unavailable for 12 months and it falls back on the other midwives. We agree it has to be throughout the service and not just focused on the CMS.

The experience is very different if you are in a maternity unit that is solely a maternity unit or if you end up in a general unit. Women who experience miscarriage will end up in the general accident and emergency department, which is not at all an adequate experience for them at that time.

I have a general observation which the witnesses may comment on. By improving our services in early diagnosis of pregnancy and early identification of at-risk pregnancies, not just for pregnancy loss and the loss of a baby, that improves the service for everyone. I hate bringing litigation into this but it is a reality. The cost of litigation to the State is massive. I think we are holding €5.2 billion in reserve and about €1.5 billion is paid out every year, the bulk for adverse outcomes from delivery. Is that message getting through? Professor O'Donoghue said there is no mention in the HSE service plan.

That is disappointing. Even in the Department of Health strategy, I think, there is just a mention of finishing implementation of the maternity strategy itself. That is why we have tried to put all of the evidence in that area together in an action plan to join it all up. It is not just informed by the evidence but trying to put together doable pieces and pillars of work to show in this document how that can be done and how to do it in ways those of us who have implemented things before know can be done. It is trying to put it together in the form of pieces of work people can see can be done. The Deputy is quite right; we have talked a little more about earlier pregnancy loss, but when we look at neonatal death, babies who die within the days after they are born, the leading contributor is pre-term birth. Some of that is spontaneous, unprovoked and not predicted and some is because of other problems in the pregnancy. There is a lot we can do to uplift maternity care by focusing on these significant types of outcomes. It will certainly have improvements in many different conversations in our maternity services.

It is a point that is missed all the time. People talk about the cost of putting staffing in place, but it is not a cost at all. It is an investment in the service and in being able to deliver safe, quality care. The outcomes are so much better. We believe it is necessary to legislate for safe staffing because all the research from around the world shows that if you have safe, appropriate staffing in place that can meet the needs and demands of the service based on complexity, dependency or whatever, the outcomes are so much better. Mortality rates go down and failure to rescue goes down. Then there are the outcomes for the people who work in the service. They are more satisfied going to work every day and they know they can go to work and deliver a safe service. That gives them such great psychological support as well in going to work and delivering a safe service. That investment is not a cost at all, it is an investment. The Deputy talked about litigation and the cost. Compared with the budget for maternity services, it is incredible what the costs are. If safe staffing is invested in across the board, that will ensure a better service for mothers and babies.

I thank the witnesses for their comprehensive answers. Is there a tension between overmedicalisation and demand? On the one hand we are talking about trying to bring people to the most appropriate place for the most appropriate care - the least complexity in the least complex site. Evidence would say that is safe. On the other hand, we have a rising Caesarean section rate. I am not sure what is driving this. Is it defensive medicine? Is it patient demand? Is it a combination of both?

It is all of the above. There is no doubt there are increasing complexities leading to recommendations about some types of interventions such as the timing of birth. Then there is a fear as to what the interventions materialise into and what they mean in the care experience. We referred to higher rates of induction of labour, and women quite rightly have a fear about how that might be managed, the delays that might be involved, how that is managed in our services and the environment in which they are looked after. That leads to a fear of the uncertainty of that outcome. That is where experienced staffing, continuity of care and trusted healthcare professionals being there throughout the pregnancy experience and at the end can really make a difference. That is a feature. My personal opinion is also that the increasingly medico-legal culture we have to practise in in the world of maternity services and the enormous personal and professional impact that has on all of us as staff is a huge factor in the changing practice in obstetrics. That is not to anyone's benefit.

The issue about the Rotunda was raised earlier. My wife worked there as assistant master in 1997 and 1998. It was hugely challenging at the time. Some changes were made but it is disappointing that it is still not progressing when there was a need for change 20 years ago. It comes back to the other 18 units and whether we should now do a review of all 19 units to see what work needs to be prioritised to increase the space for people to work in and for people attending for delivery. Part of the strategy we should be looking at is a review of that whole area. Has enough been done in the area of adverse outcomes in hospitals and the support for patients, in particular mothers and their partners? The other issue relates to support for staff where there is an adverse outcome. For instance, I have come across cases where, when there were adverse outcomes, staff members were turning up to inquests with very little support being given to them, either before attending or after the inquest, which is also important. Does a lot more need to be done for the parents and the staff? It is traumatic for staff.

They have done their best and what occurred was outside their control. They then have to go back to work in the following days or weeks. Do we need to do a good deal more in that area?

I would argue that we absolutely do. A lot more needs to be done. These are adverse events and as we talked about, they will have an impact on the women involved for years and decades. They will impact the midwives. Whatever happens lives with them for a long time. There are systems review processes within the HSE. They are quite traumatic for the staff who are involved. They are quite adversarial. The whole culture around that needs to change.

Doctors, nurses and midwives are regulated, etc. The people making decisions with regard to the staff who are in place and the resources that are provided to the service are not the ones who end up before the medical board or the Nursing and Midwifery Board of Ireland, or in front of coroner's cases. It is important that the people who now carry all of the responsibility get a say in the resources that are put in place and provided to the service. Not enough is done to support the staff, the mothers or their families in that scenario. Significant work needs to be done in that regard.

I referenced the Renfrew report in Northern Ireland. It talked about improving integration and teamwork, strengthening the workforce, focusing on prevention in public health and data, learning and quality. We have the data, but what is the learning? Something is then lost. We know what the learning is but there is a gap then with regard to policy, implementation and operationalisation. We believe that not enough supports are in place in that regard. The priority must be safe, respectful care for mothers and babies. We need adequately supported staff with educational opportunities, training and all the other pieces that go with it. The priority now is to note that finances and headcounts take too much control.

I will speak to the review of baby deaths specifically and to the impact on parents and staff. A number of different review process currently exist in our hospitals and across our systems. They are not standardised across hospitals and regions. We know from feedback from parents, our experience as clinicians and research evidence that the current system for reviews of baby deaths, which should be about informing and learning for the future for the person, family, hospital and system, is confused and adversarial, and is not working. Part of the pillar in our action plan is to try to find a system to better review baby deaths. James Walker commented years ago that you should review once and review well. Now we are reviewing many times and there is a lot of fallout from that, personally and professionally, for everyone involved.

Is it the case that parents, in particular, find themselves compartmentalised-----

Yes, absolutely.

-----where there is a lack of connectivity?

The current systems definitely isolate parents. I am afraid that while the coronial system of investigation into perinatal death is well-intentioned, its application to the majority of perinatal death since the legislation change in 2019 has resulted in an increasing number of deaths, going down that legalistic framework into review. That has prevented learning for the professionals and hospitals, and the parents are very isolated in that process.

There is also the time delay.

Yes.

For instance, if junior doctors are involved, they are moving to other hospitals and are not available for interview-----

That is absolutely the case.

-----for various reasons.

I spent Monday attending an inquest for a death that occurred in May 2024.

As a parent and grandparent, I would love to believe that there was learning from my daughter's death. I would love to believe there was learning from my grandson's death. However, I do not. Others probably feel the same. It is not that people, the midwife, in my grandson's case, were not giving very good evidence. I could see the impact it had on her. However, I do not believe there were any learnings from any of those. We hear every day that parents go into the coroner's court for the first time. It is probably the only time they ever have anything to do with the legal profession in this way. It further compounds the tragedy of the loss of the child and retraumatises them. Some of our parents are waiting to see can they proceed with another pregnancy because of their age, etc. It is not serving anybody. I know it was well-intentioned, but I cannot see the point of it at this stage. As parents, we cannot see the point.

We might move to the next question.

May I make one comment?

I ask Mr. Fitzpatrick to be brief.

The Deputy asked about the infrastructure. If we assessed every unit in the country, there would be benefits. Women in a modern maternity service deserve to have care in modern facilities where their dignity and privacy are respected.

With regard to the national maternity strategy around the delivery of midwifery-led units and the improvement of home-birth services, we now have concerns about free birth and women choosing to birth outside maternity services. That must be addressed in the future maternity strategy.

I thank Ms Dixon. I apologise for cutting people off but I am keen to give everybody the same amount of time. We have a hard stop at 12 noon and I want to get everybody back in. I call Deputy Clarke.

I will ask something of an open question. I know I will leave this room with the statistic that more children are lost to stillbirth than there are people killed on the roads. That statistic will follow me when this meeting is over. For the national maternity strategy, what are the top three things that need to change to ensure that resonates with people who are pregnant today, who may have lost a chid in the past or who will become pregnant in the future? What needs to change in the strategy to put that front and centre and to ensure that the strategy delivers for the staff who are working in the hospital, the parents who experience a loss and those who we want to work in the service and who will be delivering babies in the future?

The strategy is ultimately just a document. That is the whole problem or point. It is like when I was handed implementation of the bereavement standards. It was a document.

It is about implementation.

Yes. We obviously need to involve all the relevant people in creating the strategy. That includes many of the people around the table today as well as the wider group. We need to involve not just the obvious people but also some of the people like us who the committee has chosen to speak to it today.

Does responsibility for delivering on it-----

It is about the implementation of it.

Does the implementation need to lie with the regions or does it need to lie nationally?

It needs to be driven nationally. I have talked a lot about the national women and infants health programme, NWIHP. I work with the programme. I lead the guideline programme and led in bereavement standards with the programme. Our work has been well supported by the programme. The committee heard me say earlier that despite regionalisation, there needs to be national standardisation of what we do. There needs to be leadership centrally, but the regions need to be accountable to that structure. We need an implementation lead and working group. We need work streams from that working group. Everybody needs to be around the table for the implementation of the strategy.

We are short on time.

If we were to do something today, it would be to resource an implementation lead to look through all the different guidelines we have on paper. A lot of the work for this strategy has been done but we do not know where some of the gaps are. We have highlighted some in respect of, for example, recurrent miscarriages. Not all women are receiving the same high-quality care. We talked about reduced foetal movements guidelines. People are not being given the educational material they should be given.

Another example is foetal growth restriction. We know cases are being missed during care even though we have guidelines. If we had that lead, he or she could go and work with the maternity units, not with the intention of ascribing blame or asking why something is not being done but-----

It would be about raising standards and unification.

Exactly that. It would also be about understanding. Perhaps the issue is a lack of time or training. The lead could find out what the issue is. It could be different in every unit. It would then be about addressing those differences. Perhaps a particular unit cannot do something. That could then be documented and we would know why. There might be a valid reason. We need to ensure that what we have published is implemented and we need that data. If we do that now, we could fulfil the current maternity strategy before we move to the next one.

We absolutely concur with all of that. It must be nationally led and cannot be left to the regions. The accountability absolutely must be held within the regions, but it needs to be driven at a national level. An implementation plan is required with individuals who are clearly given the role and function of ensuring implementation of the plan. That is key. We need to legislate for safe staffing. It is so important around the issue of culture and delivery of care that staff have the time and resources to deliver care.

We must acknowledge that all midwives and doctors go into work every day to do a good job and provide good care. There have to be national standards that look at individual practices and units, and how standards are implemented with the resources and infrastructure that are there so the best care can be given to women. Every unit practices individually. The infrastructure is there but the culture is different. Human factors and all of those things play a part in how women experience care and how it is delivered.

I am struck by how many people in this room and across the country are touched by baby loss or infant death, the lack of awareness and discussion around it and the need to continue this conversation and awareness within the Oireachtas, wider society and the media. Hopefully, the committee can help do that over the term of this Oireachtas.

We see time and again implementation deficit disorder. It is there on paper but not in practice. It is a really good report but has not been implemented. It involves recommendations that are not implemented. This is a real challenge for the State. We see it time and again across services and we hear it again today.

I will pick up on the staffing piece, because that needs to be addressed. What is the impact of the pay and numbers strategy? We have issues with a lack of public health nurses in the community, which is having an impact on postnatal care and leading to a post code lottery. I am interested in hearing the witnesses' thoughts on those issues.

We believe staffing is critically important. It is not just midwifery; it involves obstetricians, junior doctors working within those teams and all the staff involved in the delivery of care. We believe this issue needs to be addressed. The pay and numbers strategy is having a decimating effect on services. The HSE states that we have way more staff in the service than before but in the context of comparisons between that and activity levels, the Department has done the research and has the needs assessment report on the growth in demand for all these services. I will not go into all of that. The Department's projections are clear. We have a problem with regard to providing sufficient numbers of healthcare staff to provide care. The trajectory of that is increasing as the older population grows. All of those factors are increasing, so we need to plan.

The question is asked as to what time is best to plant a tree. It is actually 20 years ago. The reality is that things are not happening now to ensure we have the workforce in one year's time or two, three, ten or 20 years' time to meet the demand. The pay and numbers strategy leads to a situation where directors of midwifery, clinical leads and obstetricians do not have the right to say "Somebody is leaving this post, so I need to replace them and bring someone in", or "Somebody is going on maternity care, so I need to go and recruit". Many of them know the people who would work within the service but they have to go through an arduous process to get approval within their regions and probably nationally at times to fill those posts. That comes back down through the regions and it could be six months before they get the approval and when they go through the recruitment process, it can take up to 12 months to get the staff in so it is having a terrible effect on the services as they exist now and it needs to be addressed.

Public health nurses have a big role to play with regard to first visits while GPs obviously have a role with regard to immunisation. It is vitally important. The First 5 strategy was referenced. Those first five years are critical. We need adequate numbers of public health nurses in the service. As a result, a lot of work needs to be done increase the number of training places for midwives and public health nurses to ensure that pipeline is there because midwifery and the public health nursing service both have an older profile.

There is an absence of succession planning. We have one perinatal mental health midwife and one bereavement midwife. If something happens, there is a gap in the service. We now know that public health nurses are not always midwives so there is probably a deficit sometimes in the care that is given to women in the postnatal period and that community midwifery aspect really has to be supported in the new maternity strategy.

It is extremely challenging for public health nurses where they are delivering clinical care, elderly surveillance and child health so there are a lot of conflicting issues that need to be addressed with regards to that. They do incredible work. As someone pointed out, there are about 1,400 of them. The same number of people as the nursing population in the Mater Hospital are providing a massive national service that is set down in legislation from the 1960s.

There is no such thing as out of hours when your baby is dying or you experience a miscarriage and have to be sent home. There is no awareness either that a miscarriage is a hugely emotional and traumatising time for a woman. It is also physically painful. There is so much going so we are calling for adequate staffing and out-of-hours clinics to make women feel safe and to care for them at a hugely traumatising time for them.

It is worth reminding the committee that 20 years ago, what is commonly called the Our Lady of Lourdes hospital report - the Harding Clark report - was published. I read that report frequently because I find it to be full of common sense and excellent recommendations. If the Cathaoirleach permits, I will read a couple of lines from it. It really summarises everything we have been talking about, although it does not relate to pregnancy loss specifically. Recommendation number eight of the report states:

Change, analysis, review and learning are the keys to best practice. All procedures must be measured against outcomes and modern literature must be considered. Medical practices must be evaluated against accepted benchmarks. Fresh ideas must circulate; education must continue and review of outcomes must take place on a regular and continuous basis. Each unit must be associated with other units and compared constantly with each other and against known standards. Leadership, training and knowledge must be recognised as key elements in every successful hospital. Support systems must be in place to enable standards to be reached and maintained. The professional bodies must play a fuller role in evaluating competence. Society needs good doctors and nurses. They deserve good working conditions and their good work should be rewarded and appreciated.

Deputy Sherlock asked a question about home births. She could not stay with us and is now on her feet in the Dáil. Will one of the witnesses answer her question?

The previous national maternity strategy is outdated because we have the national HSE consent policy. Much has changed in that time. The strategy talked about midwifery-led units, which has not changed at all during that time, and a HSE home birth service. The idea was to move the home birth services into regional areas. That was considered to be the job done but that is far from sufficient. There is a lack of access and it is a geographical lottery. Then it is a lottery as to when one get a midwife. There is lots of good evidence to support home birth. As I referenced earlier, a lot of women are now choosing to give birth in their home unassisted by any medical professional so services become more restricted without access to medical professionals.

This has been shown in Northern Ireland as well, which was why the Renfrew report was produced, because there was a closure of midwifery-led units there. The rise in freebirthing is an issue of concern. Deputy Sherlock referenced the situation in Limerick. There was an adverse outcome there but the entire service was shut down within that region. We also know that tragically there are reports of deaths in the emergency department of UHL but they do not close the service. The home birth service in Limerick was shut down. There needs to be a review of this and a framework around it. The strategy talked about home births. I have to reference the midwifery-led units in Cavan and Drogheda, which are well established and well resourced. We can compare the two units and see the impact of culture. There was a reluctance in Cavan with regard to the provision of that service but it has survived. The one in Drogheda is thriving. There is certainly a role for that. It is incredible that there has been no further roll-out in ten years.

That concludes our consideration of the strategy. I thank our witnesses from the Pregnancy Loss Research Group, Féileacáin and the INMO. I thank them for their time, work, advocacy and research. I know a lot of preparation goes into a session like this, but the witnesses have also engaged in a great deal of work on these issues over a long period. I thank them for all that work and advocacy, and for representing workers as well. This is not the end of our consideration of these matters. We will be back to talk about the maternity strategy next week with the HSE and the Department of Health. Hopefully, we will have ongoing engagements on this matter.