Northern Ireland Assembly Flax Flower Logo



Perinatal Psychiatry Services

17 April 2008

Members present for all or part of the proceedings:
Mrs Iris Robinson (Chairperson)
Mrs Michelle O’Neill (Deputy Chairperson)
Mr Thomas Buchanan
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mrs Carmel Hanna
Ms Carál Ní Chuilín
Ms Sue Ramsey

Ms Mary Duggan ) Community Practitioners’ and Health Visitors’ Association
Dr Janine Lynch
Ms Shona Hamilton ) Royal College of Midwives
Ms Breedagh Hughes )
Ms Patricia McStay ) Southern Health and Social Care Trust

The Chairperson:

A few weeks ago, the issue was raised of a lack of services for new mothers suffering from mental illnesses. The Committee has invited the Royal College of Midwives and others to brief it on perinatal psychiatry services. A briefing paper has been provided by the Royal College of Psychiatrists.

The Committee welcomes the following witnesses: from the Royal College of Midwives, Breedagh Hughes, board secretary and Shona Hughes, chairperson; Patricia McStay, head of midwifery services at the Southern Health and Social Care Trust; Dr Janine Lynch, consultant psychiatrist; and Mary Duggan, chairperson of the Community Practitioners’ and Health Visitors’ Association.

Ms Breedagh Hughes ( Royal College of Midwives):

I know that the Committee has a deep interest in suicide generally and that it has initiated a suicide inquiry. However, suicide in pregnancy, and among women who have just delivered a baby, is very much a hidden problem in Northern Ireland. A few years ago, by marrying up separate confidential inquiries into maternal deaths and suicides, we realised that suicide is the biggest indirect killer of pregnant women and of those who have recently given birth. Dr Lynch will talk about that in more detail.

That discovery led to the Bamford Review taking a very timely look at perinatal mental health. I have circulated two documents. The first contains the main Bamford Review recommendations on perinatal health services and was published in 2005. None of those recommendations has yet been implemented in Northern Ireland. The second is a subsequent paper on alcohol and substance misuse in pregnancy. The two papers are related. Members will hear more about that from Dr Lynch.

Each of the organisations represented here — midwives, health visitors and psychiatrists — is concerned about what is very much a hidden issue in Northern Ireland. We are aware of two young women in west Belfast who hanged themselves in the first three months of this year. For a variety of reasons, their deaths — and those of young men who commit suicide — are reported differently. Perinatal suicide is still very much a taboo subject, and there is the issue of the surviving child and how best to protect him or her in the future. Therefore, for all sorts of reasons, the problem is hidden, but it deeply concerns all three of our professions.

We welcome the opportunity to speak to the Committee. We will be happy to take questions later. Dr Lynch will now lead off.

Dr Janine Lynch:

I echo Breedagh’s thanks to the Committee for allowing us to present our ideas for improving perinatal services.

The birth of a new child is a critical period for any family. It is a period of great joy but also of great stress. After delivery, there is no doubt that mothers are at increased risk of psychiatric conditions that affect not just them, but their newborn babies and other family members.

Psychiatry often finds it very difficult to offer advice about the primary prevention of mental illness. We know that long-term mental-health and psychological adjustment are influenced by an individual’s early environment as well as his or her genes. Therefore, if we can intervene to reduce the incidence of maternal mental illness, it will have a beneficial effect on mothers and on their children’s future psychological health.

Psychiatric disorder associated with child birth is common and often serious. It can occur as a first presentation or as a deterioration or recurrence of a previously diagnosed illness, such as manic depression. We can identify risk factors for some illnesses, and have a unique opportunity to screen for them during the antenatal period.

Preventative measures may be an option. Liaison between psychiatric and maternity services is essential in promoting psychological well-being and to ensure best possible outcomes for mothers and babies.

Puerperal mood disorders occur across a spectrum of severity, ranging from mild, benign and self-limiting baby blues, through to anxiety and depressive disorders, to a very severe illness called puerperal psychosis.

At one end of the spectrum, all that is required is simple reassurance; at the other, hospital admission and specialist treatment are needed to prevent adverse outcomes. In between, there is a mixed bag of diagnoses, requiring medication, psychological intervention, social support or a combination of all three.

Most interventions can be provided within primary care, so long as staff receive adequate training and support from secondary services. Specialist services are needed to treat more serious depressive disorders and psychotic illnesses at the severe end of the spectrum.

Perinatal psychiatry is not a new idea. Australia leads the way in its development, and during my training, I was lucky enough to spend some time there, learning how relatively simple interventions can dramatically improve outcomes.

There are well-developed services throughout England, Scotland and Wales, including a number of mother-and-baby units. Within the past five years, Scotland has opened two such units, one in Edinburgh, the other in Glasgow. Scottish mental-health legislation enshrines the right of a mentally ill woman to be admitted to hospital with her baby.

The drive to develop services has been given impetus by the three confidential inquiries into maternal death. The first two stated that suicide was one of the leading causes of maternal mortality. The most recently published inquiry found a decrease in suicide, suggesting that the message from previous inquiries about the provision of specialist services was being heeded.

Northern Ireland lags well behind in the provision of perinatal psychiatry services. We have no recognised structure for the provision of mental-health care in pregnancy. There is no specialist facility for the admission of mentally ill women and their babies. A confidential inquiry and our own Bamford Review recommendations are highlighted in the National Institute for Health and Clinical Excellence (NICE) guidelines on antenatal and post-natal mental health, which state clearly that perinatal services should be provided as a specialism.

There are individual examples of very good practice, but overall services are patchy and inconsistent, and there is no regional development strategy. I have submitted to the Committee a summary of how we can take forward services. I am happy to arrange private meetings for Committee members who want to talk with women who have suffered from perinatal illnesses.

Ms Mary Duggan (Community Practitioners’ and Health Visitors’ Association):

Health visitors are primarily concerned with the health and well-being of children aged up to five, and that of their families. I have had a special interest in post-natal depression and perinatal mental health for more than 20 years and made a submission to the Bamford Review several years ago.

We are discussing public-health issues that affect not just the mother but her partner and children. Evidence shows the impact on children is far-reaching for their emotional, cognitive, educational and behavioural development. Longer treatment studies provide evidence that children can continue to be affected until the age of 15 or 16.

Health visitors are involved in screening for the illness from the antenatal period right through until children start school. Practice varies in certain trusts, and services received by a presenting mother almost amount to a postcode lottery.

Health visitors are more concerned with the management of post-natal illnesses with the GP and the primary care team. We also try to take account of the child’s perspective by considering the bonding process and, in some cases, children’s safety.

I welcome the debate and opportunity to come before the Committee. It is very important that we have a multi-disciplinary approach to moving forward with what is clearly a major public-health issue.

Ms Patricia McStay (Southern Health and Social Care Trust):

Good afternoon, ladies and gentlemen. I speak from a service manager’s perspective in reflecting the frustration of staff across trusts at the lack of services for women with perinatal mental illness, and the lack of specific training programmes on perinatal psychiatric disorders for midwives, obstetricians, GPs and health visitors. Training and education are paramount to professionals, as is a mental-health framework to deliver to mothers the services that they require.

Pregnant women are asked at their antenatal booking visit about current and previous mental-health problems. There are limited services and resources to care for women who require onward referral. Every service needs clear referral and management protocols across all levels; clear pathways for service users; defined roles and competencies for all professional groups involved; and clinical networks established for perinatal mental-health services. These must be managed by health care professionals, managers, service users and carers. In some areas, mental-health and maternity services are examining ways to enhance these services through closer working practices and interfacing within trusts.

Out of the 26 maternal deaths by suicide in the last ‘Why Mothers Die’ report, only one woman had been admitted to a mother and baby unit. The new mental-health unit at Craigavon is an ideal location for a mother and baby unit. It is central to all maternity units in the Province, and to those units south of the border. It is situated alongside an acute maternity and neonatal service, which is ideal for those women with pre-existing conditions that may necessitate the delivery of a premature baby. We urge members to help us to pursue these issues.

Ms Hughes:

That concludes our presentation. Shona will answer questions from a clinical perspective as a midwife. She works in the South Eastern Health and Social Care Trust, and is the chairperson of our board. She manages a labour ward, and has a very keen professional interest. She will take clinical questions, while Patricia is happy to take management questions. Mary will take health visitor questions, and Janine will take psychiatry questions.

Dr Deeny:

This is of extreme interest to me as I have been a GP for years. I am aware that such initiatives are happening in Scotland and elsewhere, but, here, we always seem to be behind everyone else. That may be something to do with what has gone on here for the past 30 or 40 years; however, the past should not be used as an excuse when dealing with health issues.

I have been in the National Health Service for over 20 years and have watched the administration side grow. I remember admitting a patient of mine who was very ill with puerperal psychosis. I know that lady to this day. She was admitted to an old local general hospital, was seen once a week, and was getting worse. I remember one day thinking that it was shocking that we did not have adequate facilities for ladies who are very ill. It took her a long time to recover, and I had to move her from the local hospital to the Belfast City Hospital where she was given more close attention. I would not say that it was one-to-one care, but that is what I had to do. That was 18 years ago, and nothing has changed.

Other things are happening in the Health Service — for example, the explosion of administration — and yet a service that is needed by our mothers is not available. This situation is a shocking indictment of the various health departments through the years.

Is there an understanding in the Department that this care is needed in modern day health trusts? I am very interested in how this would happen in practice, as I have no doubt that fewer people with mental-health issues should be treated in the old, dull, dark, depressing hospitals, as it could make the situation worse. We would prefer to treat such people in a more community-based way. How would that work in practice, an appropriate liaison with the primary health-care professionals? I believe that this perinatal service is needed, and the mother and baby unit — they are absolutely essential. The two cannot be separated. Does the Department of Health, Social Services and Public Safety accept that, as matter of necessity, it must provide services to mothers?

Secondly, how will community treatment work in practice? What do I do if I get a patient on a Friday whom I do not want to send to an adult psychiatric hospital, because doing so might worsen the situation? Is there a crisis team? Is there someone whom I can contact if I am concerned about a new mother’s mental health over the weekend?

Ms Hughes:

I will pick up on the first part of the question, and Janine will address the second part.

The Department commissioned the Bamford Review and is aware of the need. The review clearly and unambiguously recommends the creation of a regional specialist mental-health service. It also states that a regional needs’ assessment should be carried out to establish any requirement for inpatient mother and baby facilities. Since the report was published in 2005, neither of those two things has happened.

Other recommendations include establishing protocols for managing perinatal women at risk of a relapse or recurrence of a previously existing mental-health disorder, and a comprehensive assessment of maternal health, including mental health.

Currently, a midwife booking a mother-to-be into treatment records her mental-health details, as part of a full history. If it emerges that the woman has already had contact with mental-health professionals, she has some chance of receiving perinatal psychiatric care during her pregnancy. Janine will expand on that point. However, if it does not become apparent that she has a problem until during the pregnancy or birth, there is no specific point of reference for the midwife, health visitor or GP who has become concerned.

The Bamford Review recommends that women with a history of serious, non-pregnancy-related mental disorders should be offered psychiatric assessment during pregnancy. A management plan should also be put in place, because such patients are at high risk of a recurrence following delivery.

The recommendations state that substance-misuse services should be allowed throughout antenatal care. A subsequent paper deals specifically with substance abuse and includes very clear, specific recommendations, which were made by the Bamford Review team to the Department.

Therefore, in answer to the first part of the member’s question, the Department has been well aware of the issue for years.

Dr Lynch:

Touching on that — I suppose that one of the difficulties is that, historically, mental-health services in general have been badly funded.

Speaking as a general adult psychiatrist, the idea of a specialist perinatal psychiatric service is so new that the public may question the need for yet another specialist service and assume that funding it is a matter of robbing Peter to pay Paul.

At the moment, there is nowhere here where a mother and her baby can be admitted together. General adult psychiatric wards used to do so, but it is no longer regarded as safe practice, and the Royal College of Psychiatry disapproves. Staff lack proper training or facilities to nurse mothers and babies in an acute inpatient ward, so women are not admitted with their babies. That applies throughout the island of Ireland, but is not the practice across the water, where there are mother and baby units.

Depending on the severity of their illnesses, some women can be cared for very well at home, with help, if needed, from home-treatment or crisis-response teams. However, a seriously ill woman who must be admitted presents a risk to herself and, occasionally, her children.

Mr Easton:

Do GPs assess the mental-health condition of mothers before they are admitted for treatment anywhere in Northern Ireland? The witnesses are indicating no — so should GPs be the obvious first point of reference for assessment?

Ms Duggan:

I take it that the member means through screening. From a health visiting perspective, we informally assess a mother every time we have contact with her, through asking how things are in general and they are.

At certain periods — between six and eight weeks and at four months — we do a formal assessment. Obviously, if we have any concerns about the mother at that stage, we liaise with her GP, who is doing the same thing. At each contact they have with the mother, they informally assess her mood, how she is coping and generally how things are.

Trusts conduct formal assessments at certain stages. The stigma associated with perinatal psychiatric illness is a difficulty that we try hard to eradicate through discussion. The establishment of a perinatal strategy and a specialist service may eradicate, or go a long way to reducing, that stigma.

For six years, I worked as a specialist health visitor for the mental-health directorate in the Magherafelt and Cookstown area. I worked specifically with that client group, alongside a community psychiatric nurse. At that time, specialist health visitors were widely accepted by mothers who were deemed to be suffering from the illness, which was known as post-natal depression. The term was acceptable to mothers, who were happy to be referred to us, whereas they were not happy about being referred to a psychiatric nurse. As professionals, we have much work to do to reduce the stigma that many people attach to mental-health problems. That is a major factor in people being honest about how they feel.

The other issue concerns what we can offer to mothers after their diagnosis.

Mr Easton:

Is a lady, who has given birth, assessed before she leaves hospital?

Ms Hughes:

A midwife carries out an assessment.

Mr Easton:

Does that happen in every case?

Ms Hughes:

Yes; it is part of the discharge planning.

To return to the point about GPs, their increasing workload in other areas means that many have no contact with pregnant women. The care is provided in the GP’s surgery, but a team of community midwives care for the woman throughout her pregnancy. Generally, they work in tandem with the hospital into which the mother has been booked for confinement. Often, as part of the booking procedure, the midwife includes screening for mental-health problems when taking the woman’s medical history.

However, whether the woman discloses any such problems is discretionary. If she has had contact with mental-health services, her GP is involved with her care, to which there is a multi-professional approach. However, if she has no such history, the first indication of a mental-health problem is often after her baby has been born. We are trying to raise midwives’ awareness of the importance of screening women before they leave hospital, but there are training implications. Training is not consistent, and women are transferred from the care of the hospitals to the care of community midwives. Generally, there is little GP intervention unless the women have pre-existing mental-health problems.

Ms Ramsey:

I will focus on the 26 maternal deaths through suicide that were mentioned in the opening statement; although it may be difficult to go into those in much detail as the Committee is in public session.

Ms Hughes:

There were 26 deaths across the UK.

Ms Ramsey:

Two deaths in west Belfast were mentioned, and I knew one of the young women concerned. It strikes me that we must try to put a human face on the subject. The statistic is that 26 women died, but the impact of each death on new-borns, older children and society is extremely negative.

Breedagh, your paper repeatedly refers to a confidential inquiry, which is fair enough, and you mentioned several reports. How many times must confidential inquiries produce reports and recommendations? Is there a baseline from the first to the last inquiry? What were the recommendations of the first inquiry? I am sure that they must be similar to those of subsequent inquiries. What happened to the first report’s recommendations? Were any implemented before the most recent inquiry took place? Has there been any progress? You may be unable to answer some of those questions, in which case, it would be useful to request responses from the Department

I understand why the inquiry’s report is confidential but, if possible, Committee members should have sight of it. The 1997-99 confidential inquiry recommended that every health authority should have a perinatal mental-health strategy, but is that now the case? Several confidential inquiries have made that same recommendation, but who is heeding it?

Dr Lynch:

Other parts of the UK have made progress on implementing the recommendations of the confidential inquiry: Northern Ireland simply has not done so.

Ms Ramsey:

That takes me to my next point. The Committee’s inquiry into suicide and self-harm is under way, and everyone is aware of the Bamford Review. If it emerges that this issue is directly, or indirectly, connected to that review, will any lessons be learnt, or will the Committee’s report simply sit in the Department? Off the top of your head, how many confidential inquiries have there been?

Ms Hughes:

Three confidential inquiries have highlighted suicide as an issue in maternal deaths. The results and reports of the confidential inquiries are published and are available on the Internet. The confidential aspect is that the deaths are reviewed anonymously by a team of professionals. The aim is to learn lessons from those deaths; it is not about pointing a finger of blame at any health trust or service. The confidential element of the inquiries is that the women are never identifiable.

Ms S Ramsey:

That is fair enough. However, we need to deal with that issue separately and consider the recommendations.

Ms Hughes:

In England, primary-care and hospital trusts must have a robust maternity care strategy. We share in, and provide statistics for, the confidential inquiries, and the completed reports are sent to the Department of Health every three years. However, we have not developed any strategy or specialist service, nor do we have a single point of access for midwives, health visitors, GPs or anyone else who is concerned about a woman’s mental health. There is no single point for health professionals to access a service, because there is no service to access. Therefore, although measures, standards and targets have been put in place in England, Scotland and Wales, there has been no action on perinatal mental-health services in Northern Ireland.

Ms S Ramsey:

I do not intend to be flippant, but how many inquiries do we need? How many recommendations do we need? This Committee has a duty to ask what has become of the recommendations, from the first confidential inquiry to the last, and what progress has been made. You have given a great presentation. However, as individual elected activists, our job is to question what progress has been made in this area.

Ms Hughes:

We appreciate the Committee’s support. In recent years, the midwifery, health visiting and psychiatry professions have had extensive awareness-raising exercises. The difficulty is to improve knowledge among those who have direct contact with these women. For example, when a problem is identified, where does one turn? One of the reasons why we are here is to ask for help to alleviate the frustration felt by midwives and health visitors, and any help would be much appreciated.

Ms S Ramsey:

The Confidential Enquiry into Maternal Deaths 2000-02 report recommends that:

“Guidelines for the management of women who are at risk of a relapse or recurrence of a serious mental illness following delivery should be in place in every Trust providing maternity services.”

Has that recommendation been implemented?

Dr Lynch:

There is no point in having a protocol whose end point is to refer a woman to a specialist if the specialist is not there — and the specialists are not there at the moment. I am the only consultant psychiatrist in Northern Ireland who has any session time devoted to this issue, and I have only one session per week. The difficulty is that the specialists are not there. I have a number of trainees who would love to work in this area, but no posts are available.

Mrs O’Neill:

We share your concerns and thank you for coming before the Committee. I am encouraged that your three disciplines have come together to make this presentation. It is a pity that the Department does not think like that more often.

Speaking as a mother, I would imagine that, if I had given birth and had to go to hospital with a mental-health problem, being separated from my child would be the most traumatic feeling — it would probably be detrimental to the recovery process. There is a massive lack of provision in this area, and that is an issue that the Committee must take seriously and raise with the Department.

The report of the Confidential Enquiry into Maternal Deaths that you have referred to covers the years 1997-99 — is that correct?

Ms Hughes:

Confidential inquiries occur every three years and examine all maternal deaths over the previous three years.

Mrs O’Neill:

It would anger me to think that deaths could have been prevented had the Department implemented even one of the report’s recommendations. There could have been a lot fewer than 26 maternal deaths had any of the recommendations been implemented. That is another matter that the Committee will have to raise with the Department.

Training is obviously an issue. If Dr Lynch is the only person who provides training, then provision is clearly massively lacking. Does something need to be done to get psychiatrists interested in perinatal care? Does the Committee or the Department need to take more action to try to push psychiatrists in that direction?

Dr Lynch:

One difficulty has been that, for general adult psychiatrists, this has been a small part of their workload. It is a subject that one needs to devote a lot of time to. There are many issues: for example, the prescribing of medication in pregnancy is a massive issue, and it is essential to keep up to speed in that area in order to provide people with the right information. It is an area that needs the involvement of people who are interested in it and who have the time to devote to it. At the moment, there are lots of trainees; I could name six who are really interested in taking up these jobs. That is what is needed; each of the five trusts should have a psychiatrist who has an interest in this area, and sessions should be devoted to it. That would push forward the development of these services. Support and training could be offered to all the staff who are really interested in providing that care — the midwives and health visitors and so on. The interest and the will are there; it is a regional strategy and the money to push the issue forward that are missing.

Mrs O’Neill:

It is timely that you are here today. We await the Minister’s proposals on the Bamford Review, and we might even need to take evidence from you again when we see what is on the table — I am sure that the proposals will not provide everything that is needed.

Ms Hamilton, you deal with these issues every day. What is your biggest challenge? Is it fact that there is nowhere to refer women to?

Ms Shona Hamilton ( Royal College of Midwives):

Yes, absolutely. It is a huge frustration for midwives that there is nowhere to send women who need help. We work with those women every day, and we should remember that they are very vulnerable and have a lot of problems. General psychiatry services are very good, but there are time constraints; often, women are put on a waiting list and have delivered their baby long before they get an appointment.

In some cases, those women are well but run the risk of experiencing a recurrence. Psychiatrists think that it is a bit strange when, as part of our efforts to put in place a management plan, we ask them to see what they classify as a relatively well woman. There is no joined-up thinking there. Midwives have really embraced CEMACH; we use it as a learning tool. It is very frustrating that we are not able to implement the recommendations because there is no service available.

Ms Ní Chuilín:

The consultations on the equality impact assessments on the Programme for Government, the Budget and the investment strategy end next week. Your work needs to feed into that. Your profession deals with women, so it is a big problem that there is no one to whom a woman in need can be referred. I know that most members of the Committee have asked the Department questions about this issue, and about midwifery in general. Some of the responses that we have received are very bad. We are moving up the scale from one to ten — from bad to totally abysmal.

There is already a lack of midwives. If a pregnant woman is admitted before she has her baby and experiences difficulties, staff ratios are such that dealing with the problem becomes very frustrating. If it is the case that general psychiatry does not want to deal with the matter, then the situation is clearly going to go from bad to worse. I am glad to see health visitors here today — it is like going from one point to another.

What happens about medication? That is probably a question for Dr Lynch. I dealt with a young woman who was taking medication for a personality disorder, yet she had not been diagnosed with the disorder. I was concerned because she was pregnant. She probably would not have accepted any medical intervention; she was simply not stable enough to receive regular treatment.

I was very alarmed and shocked at the lack of interest, because she has had mental-health problems for most of her life. When wading through constituency stuff it becomes clear that she is not the only one. The number of young women who experience mental-health problems while pregnant is increasing. The response to deal with those problems is not there. The issue of medication, which I know nothing about, is frightening. The girl was in the early stages of pregnancy and on prescribed medication for a suspected disorder, yet with virtually no supervision at all.

Dr Lynch:

There are two aspects to the issue. First of all, the prescription of medication during pregnancy is a very specialist area. I have to constantly keep myself up to date, because it changes all the time. Often a drug is thought to be safe during pregnancy, and then a warning is issued stating that it is not safe. When I make presentations to GPs or any other group, I constantly have to update the information in them. That is how specialist an area it is; one can never be sure about anything.

The other issue concerns the use of medication during pregnancy that perhaps has not necessarily been prescribed for, or has been prescribed before the GP was aware of, the pregnancy. That is why we also need to look at substance misuse during pregnancy. That is a whole other area, and is not my particular field of expertise, but it is something that I feel very strongly about. The number of women attending my clinic in the Royal Jubilee Maternity Service who are taking benzodiazepines, for example, is scary. There are no services in place to provide education to women about those issues.

Ms Hughes:

Although we have not come today to talk specifically about substance abuse and alcohol misuse, it is the case that, just as there are no specialist perinatal mental-health services for women in Northern Ireland, neither are there any specialist substance-abuse services for women in Northern Ireland. We know that there is a drug problem in certain parts of Northern Ireland that is equal to anything that can be seen in the big English cities, and yet we have no specialist services to deal with that. That is a particular frustration for midwives working in that area.

One of the big problems is the lack of outreach services, and one of the recommendations of the Bamford Review is that such services should be established, because the women in question are the very women who will not come for antenatal care. It is a case of the midwife literally getting on her bike and tracking down those women. They tend to have very unstable lifestyles, to flit from place to place, and to be unavailable during daylight hours. It is very difficult to provide care to such women. There is absolutely no service, nor any proposal for such a service, in Northern Ireland.

Mrs Hanna:

You have obviously thought through the issues, and it is clear that the services are not available. Even as we are speaking, the number of those who are looking for the services is increasing. I should like to ask a bit more about the Craigavon site. What do you envisage there, and what are the Department’s views on that?

Ms McStay:

As I said, it is an ideal location for a brand new mental-health unit. If the direction had come that there was provision planned for a specialist mother-and-baby unit, right next door to an acute maternity service and an acute antenatal service would be an ideal location. It is accessible from the motorway, and is central to all areas. Why is it not pushed by the Department? It is there waiting to happen; we just need that extra emphasis on it.

Mrs Hanna:

Has the Department given any views or updates of its thinking on it?

Dr Lynch:

The Department has not stated any intention, as far as I am aware, to develop a mother-and-baby unit at the moment.

Mrs Hanna:

So we need to ask the Department about it.

Dr Lynch:


Ms McStay:

Ms Ramsey has asked what we are doing about it; we are all working in our own ways to try to establish the service, and we are very committed to that, but it takes emphasis, money, time and commitment from everyone.

Ms Hughes:

The Department has established a working group, led by the Southern Health and Social Services Board, to look at a framework for mental-health services. There are two midwives on that group, and they have had only one meeting. It is discussing a framework for mental-health services, but not specifically for perinatal mental-health services.

Dr Lynch:

The working group is considering publishing some minimum standards. The Department has to tell us the direction that it wants us to go in, and we it to commit to a mother-and-baby unit. A mother-and-baby unit cannot be set up overnight: they are expensive and require properly trained staff. We must learn lessons from Scotland about how the units were set up over there. We all want to see the services there and to establish the need for the mother-and-baby unit and progress that project.

Mrs Hanna:

Training is a major issue in mental health. We are always talking about the recommendations from the Bamford Review and their implementation. However, I am concerned about whether the training requirements have been identified and whether the training is even happening.

Ms Duggan:

I train health visitors in the Northern Health and Social Care Trust. All health visitors who are new to our trust do a three-day training course in perinatal mental health, and all staff attend a one-day update every two years. That level of training is patchy. I went to England to do my training; I have had an interest in the subject for over 20 years.

Ms Hughes:

Health visiting has an extra dimension because there is a concern about child-protection issues in cases where a mother is mentally unwell. There is a focus on that in health visiting.

Basic midwifery training is provided at undergraduate level. However, we would like to see more specialist training after registration. That is slowly beginning to happen, although it is in response to requests from midwives, rather than being led by the Department — the Department has not identified that as a training requirement.

Mr Gallagher:

In relation to the mother-and-baby unit, Dr Lynch’s report states that:

“The low population of Northern Ireland would not justify inpatient mother and baby inpatient units in each of the Trusts”.

I would certainly support a much stronger report from the Committee on that matter. When a mother is receiving treatment for serious mental-health problems in my trust area, the other parent — thankfully it is another parent in most cases, or another relative — may have to take the child, or children, in a car to visit her regularly. That is a difficult proposition in horrific circumstances. Why not have an inpatient unit in each trust? I do not have much knowledge about the subject, but I hear that neighbouring countries make the service extensively available.

Dr Lynch:

People do have to travel. In order for a unit to be viable and for staff to see the throughput of patients that is required for training to be sufficient — these are risky situations, and staff must be trained to a high level — at least four beds are required. That is the minimum for a mother-and-baby unit, and it is probably better to have between four and six beds.

For the size of its population, Northern Ireland can justify having 10 beds. Therefore, the option is one unit with 10 beds or two units with between four and six beds each. The throughput of patients would not be sufficient for each trust to have a unit. I understand your point, which is particularly pertinent in circumstances where there is a newborn baby and people have to travel. However, on a practical level, and to ensure that the units are safe, regional provision is the answer.

Ms Hughes:

We want a regional strategy. Individual trusts should not be left to make decisions about the type of care they might need or are willing to provide.

Ms McStay has proposed Craigavon as a convenient site for such a unit, because the Southern Health and Social Care Trust is the only one that has acute psychiatric services and acute maternity services on the same site.

The site is also ideal given that the service does not exist on the island of Ireland. In this era of economies of scale, if the service were to be developed, it could be used by our neighbours across the border, especially if the facility were to have any surplus capacity. However, I am not sure that that will be the case.

For all sorts of reasons, it is best if women are managed, when possible, in the community. That is why each trust should have a specialist service of its own with a team of highly-trained and dedicated staff who could manage women in their homes and involve their families, health-visiting teams and community psychiatric nurses. By the time a woman is ill enough to be admitted to hospital, she is very ill indeed.

Ms Duggan:

There are probably sufficient numbers for a day hospital in each trust area. I keep referring back to the fact that it is a family-based illness. New research shows that 5% to 24% of males will suffer from depression after the birth of a child. If the mother is suffering from depression, the partner is 50% more likely to do so. Those figures are evidence based.

Children can also be affected. It can have financial implications, as that can feed into child and adolescent mental-health services. This problem, and its consequences, need to be tackled head on.

The Chairperson:

I am amazed that 25% of men —

Ms Duggan:

It ranges from 5% to 24%.

Ms S Ramsey:

I am surprised that it is not 100%. [Laughter.]

The Chairperson:

Will they get services?

Ms Duggan:

Health visitors visit the family, not simply the baby. I visited a family last week who had had their first baby. I find that we are engaged much more with fathers now, in terms of paternity leave, which is excellent.

The Chairperson:

Some men might not thank you for it, though.

Ms Duggan:

When I started as a health visitor 24 years ago, I never saw the father’s face. Now, they engage with me. The father who I visited recently was upfront, and he asked me what I had to offer him. I thought that that was excellent. I asked him what he would like. He talked at length about his anxiety at being 15 years older than his partner, and about his anxiety about his partner’s health throughout the pregnancy. That made me stop and think that fathers have major issues that we should be, but are not, addressing.

The Chairperson:

There are issues about jealousy and resentment.

Ms Duggan:

We have to be aware that the potential exists for fathers to suffer from depression. If the mother is depressed, the father is 50% more likely to develop depression.

Ms Hughes:

I thank the Committee for listening to us. We have had a frustrating few years. We have tried to have these issues put on the agenda. We have run study days and seminars, and we have lobbied everyone that we can think of. However, there appears to be blankness in the Department about these issues.

It is a regional issue; it is not something that individual trusts or individual practitioners should be dealing with. A robust regional lead to tackle the problems is required. A strategy that enables trusts to develop protocols to work within is also required. Furthermore, a clear direction is needed, because nothing is currently in place.

We are aware that we are falling further and further behind England, Scotland and Wales. That is frustrating for those of us who have continual professional contact with our colleagues in those countries. The people who are suffering most as a consequence are the women and their families — it is the families who have to pick up the pieces.

The Chairperson:

I propose to Committee members that we send a transcript of today’s evidence session to Michael McGimpsey in the hope that, when he reads it, he will feed it in to the review.

Also, I would like to meet some of the ladies that Dr Lynch has referred to, and it would be a nice idea if the Committee, or those members with a special interest, could join me. We learn an awful lot more when we talk to the people who have come through, or who are going through, that situation.

Dr Lynch:

We would be very happy to arrange that visit at any stage.

The Chairperson:

The Committee Clerk will contact you. Those of us who want to go along can make the necessary arrangements.

Thank you all for giving us food for thought. We support the concept of a regional centre.