National Maternity Services: Motion [Private Members]

I move:

That Dáil Éireann:

recognises:

- the need for Ireland’s maternity services to be as safe as possible for women and babies, including the need for women to be listened to and respected;

- the hard work, skill and dedication of all staff across Ireland who provide maternity services;

- the growing crisis in maternity care for reasons including:

- outdated and inadequate hospitals;

- limited diagnostics;

- poor staffing ratios;

- insufficient parental supports;

- wide geographic variations; and

- lack of community-based options for mothers;

- the deep concern these pressures are resulting in for current and expectant mothers and fathers; and

- the increased burn-out and stress for clinicians, together with a retention and recruitment crisis and chronic staff shortages;

notes:

- that the 2008 KPMG Independent Review of Maternity and Gynaecology Services in the Greater Dublin Area identified the need for maternity services to be co-located with adult acute services;

- the repeated announcements from 2013 onwards, including in the Capital Plan 2016-2021 and the National Maternity Strategy 2016-2026, that Dublin’s three maternity hospitals and Limerick’s would be relocated, with:

- the National Maternity Hospital to St. Vincent’s University Hospital campus;

- the Coombe Women and Infants University Hospital to the St. James’s campus (to happen in parallel with and be tri-located with the National Children’s Hospital);

- the Rotunda Hospital to the Connolly Hospital campus at Blanchardstown; and

- Limerick Maternity Hospital to the University Hospital Limerick campus;

- the lack of progress on these essential projects, including:

- on-going delays regarding the National Maternity Hospital; and

- no progress and no budget allocation to begin the relocation process for the other maternity hospitals;

further notes:

- the numerous reports into localised maternity care issues in recent years, including Portlaoise and Portiuncula hospitals;

- the lack of progress in implementing various recommendations from these reports;

- the clinical, patient and political buy-in to the National Maternity Strategy 2016-2026, and the lack of implementation of that strategy, with no new development funding for it in 2019;

- the lack of progress on numerous issues raised in recent years by midwives, including staffing ratios, working conditions and pay inequalities, with:

- just two midwifery-led units in place; and

- a shortfall of 200 midwives below the recommended safety-levels in the National Maternity Strategy 2016-2026;

- Ireland’s low-rate of obstetricians per capita, being the third lowest in the Organisation for Economic Cooperation and Development, and being further exacerbated by a high-level of unfilled posts; and

- the rise in State payments in compensation for incidents in maternity units, up from €4 million in 2007 to almost €120 million in 2017; and

calls for:

- a definitive time frame and funding deployment for the relocation of the stand-alone maternity hospitals;

- progress to start in 2019 on all projects not yet commenced;

- a guarantee from Government that new public maternity hospitals will not have separate external or internal entrances, nor separate facilities within the hospitals, for private patients;

- funding and a task force to implement the National Maternity Strategy 2016-2026, including choice around birth, types of antenatal care, access to anomaly scanning, breast-feeding, counselling services, public health, domestic violence supports and

appropriate staffing levels;

- an active clinical programme for the development and review of clinical guidelines for maternity services;

- an immediate statement of maternity services available at all sites, including prenatal screening, access to foetal medicine, counselling, genetic testing and laboratories being used;

- investment in community-based pathways to ensure choice for mothers;

— indemnity to cover practice nurses who give antenatal care;

- measures to address the chronic staff shortages, including ending pay disparity; and

- investment in a national foetal magnetic resonance imaging (MRI) programme and bereavement care.

"I was treated like a slab of meat" - that was Róisín's testimony. "The registrar fell asleep while debriefing me after I had had a haemorrhage" - that was Lucy's experience. "I was baldly told there is no heartbeat, your baby is dead" - that was testimony from Anne. "My baby died seven days after birth, I was left in the ward with mothers and their babies while I was sick and childless" - that is what happened to Breda. Eileen recalled that her daughter miscarried while sitting on a chair. Helen has shared the following: "My baby was so disfigured from the forceps that she was taken away for chromosomal testing, a doctor came in, looked around and said, "Oh my God, what a mess, clean this up"."

Earlier this year, the country listened in horror as women from all over Ireland shared their experiences of maternity care on RTÉ's "Liveline" and the conclusion was, once again, that women are not being believed. So if no one is listening or believing the mothers, is anyone listening or believing the midwives or the doctors?

Here is what one midwife wrote:

I am in such pain following the "Liveline" coverage of women's experience of care in Irish maternity services. It is never anything short of horrifying to me that women and their families are being so profoundly hurt by experiences that ought to be, at a bare minimum, infused with dignity, respect, safety, and care.

Dangerous and unsafe is what one consultant said to me in the last two days. Another said that Ireland is not in the top 20 countries in which to give birth. Dr. Peter Boylan, former master of the National Maternity Hospital, referred to an appalling indictment of State failure. He was referring to the standard of care at the hospital in which Savita Halappanavar died. There are many other reports on other hospitals and experiences. Multiple failures were identified in a report into baby deaths at Portiuncula Hospital. The report examined the delivery and neonatal care of 18 babies and found problems with staffing, training and communication. It noted: "a significant delay between the first signs of concern and the decision to intervene".

Midwives, doctors and a host of other professionals want the best for their patients, for mums and for babies. They are doing their damnedest, but it is becoming impossible and they are burning out. There are not enough of them for a start. Right now in Ireland we have 200 midwives fewer than the number agreed in 2016 in the maternity strategy to be the safe level of midwives. We have the third lowest level of obstetricians anywhere in the developed world. By definition, if we have fewer than the recognised safe staffing levels, then our service cannot be safe. For the staff, many find themselves working in outdated buildings with outdated equipment in cramped and confined spaces, as obviously do the mums and their babies.

Just today the master of the Rotunda Hospital was forced to go public and ask for urgent assistance to build a new wing amid what he describes as "an intolerable patient safety crisis". We should listen to him. I was in the Rotunda Hospital recently and they shared with me the fact that there was a fire in the neonatal intensive care unit caused by old wiring in the walls. They said it was a miracle that no baby was hurt.

Elsewhere staff are working on MRI machines that are 21 years old that are meant to be replaced after ten years.

What of the new maternity hospitals? Four are promised but none has been delivered or even started. The National Maternity Hospital in Holles Street is meant to be on the St. Vincent's University Hospital campus by now but this has not happened. The University Maternity Hospital Limerick is meant to relocate to the University Hospital Limerick campus but that has not happened. The Rotunda Hospital is meant to relocate to the Connolly Hospital campus but nothing has happened.

In 2015 the then Minister for Health, the now Taoiseach, Deputy Varadkar, promised that the Coombe Women and Infant University Hospital would move to St. James's Hospital in parallel with the children's hospital and would be "well under construction" by the following year, which was 2016, but nothing has happened. In fact, there is not even a budget this year to begin the planning and design phase, which can take years.

What of the 2016 national maternity strategy? It is a good strategy, it is a solid plan and it has buy-in from patients, doctors, midwives and from politicians. As has become so common, there was a shiny brochure and a slick launch but nothing has happened. The new hospitals are not progressing. There is no new funding this year. In a €17 billion health budget, there is no new funding for progressing new parts of the national maternity strategy. Community-based delivery options are not being supported and in most parts of parts of the country, they do not exist. Diagnostic machines are not being replaced and there is a huge variation in the level of diagnostics and scanning available to mums, depending on where they live in the country.

In writing this motion, we listened to women, to midwives and to doctors. They said that maternity care must be safe and of an equal standard for all mums and babies, regardless of how much money people earn, that the new maternity hospitals are needed now where women can be treated with the best medical care and in appropriate settings where they can be afforded dignity and that there must be community-based options for women who do not want to use the acute system for delivery and they must have supports through pregnancy and afterwards and this includes counselling services and public health programmes like breastfeeding, which are under-funded and under-supported at this time.

This country has a dark history when it comes to women's reproductive health, and it is not solely the fault of this Government. Every party that has been in government in this State has to take some responsibility for that dark history and we must do something about it together. Think of the scandals with which we have been dealing, including symphysiotomy, CervicalCheck and the mother and baby homes, all of which relate to women's reproductive health. Nothing is happening in regard to maternity care. Brilliant healthcare professionals are burning out. They are trying to keep things going but they will not be able to do that for much longer. Mums and babies deserve better as do dads and our healthcare professionals. We are capable of much better than is currently happening. This motion, if passed, but much more importantly, if implemented, would begin to achieve exactly that.

I commend the motion to the House.

I thank Deputy Donnelly for sharing his time with me. It is approximately 12 months ago that I stood here to discuss the Portiuncula review. At the time, it was in the shadow of everything else that was going on, particularly CervicalCheck. Tonight I am again going to focus in the few minutes I have on Portiuncula. It provides a fantastic service but families have really been impacted and have lost loved ones. They have lost babies there, as the Minister acknowledged. Some 150 recommendations came out of the findings and the Portiuncula review. I was very cynical about the strategic release of the review last year. It happened within 24 hours of the CervicalCheck scandal breaking. Media coverage of it was minimal at the time. It is another shocking example of the failings of the HSE when it comes to parental care and the health of Irish women. As Deputy Donnelly said, the key findings concerned 18 cases that occurred between 2008 and 2014. Some 16 families have suffered greatly. Six babies have died. Of the 18 cases examined, serious errors occurred in ten which would probably have made a difference to the babies involved. The lengthy report included more than 150 recommendations, too many to mention. The main issues were problems in clinical care and problems with communication after delivery. The clinical care for most people attending the hospital was adequate, provided nothing went wrong. This was setting the bar far too low, hoping that everything would be all right because if it was not, God knows what would happen. Inadequacies were found in the staff's ability to interpret abnormal test results and respond appropriately, to escalate care levels where needed and to make timely clinical decisions, communicate effectively among themselves about the women and babies in their care. Surely these were basic skills that one would expect to be present in a maternity hospital at any time.

The lack of communication among medical and nursing staff on the ground was indicative of hierarchical structure, with figures who could not be questioned. The nurses on duty did not feel they could approach the consultants to have a two-way conversation. That is what was coming out of the report. On communication after delivery, it is frightening that this was similar to the problems with CervicalCheck, with information not given to women and parents in an appropriate or timely way. It is clear that this is not a once-off for the HSE but rather something that happens routinely. In only 20% of cases was communication to parents about what had happened to their baby deemed satisfactory. Most women felt they were not listened to before or during labour, that their concerns were dismissed by staff, and that no one explained how unwell their babies were and why. There was no chance to debrief about what had happened.

Women did not understand why tests or procedures were being carried out. If people do not understand what tests are about, how can they give informed consent? Technically to proceed without consent is a criminal offence. It was generally felt there was a lack of openness, which seems to be a common theme across HSE, with no open disclosure and no informed consent. How much hurt could have been avoided with open communication?

I acknowledge that since the report was published 12 months ago, a director of midwifery, an assistant director of midwifery and a midwifery placement co-ordinator have been put in place. Many of the issues that arose in the review are being dealt with and it is important to acknowledge that. However, hurt is still being caused there. I wish to put on the record the story of baby Axel, who died in January 2017 and was not part of this review. Damien and Evonne met with Deputy Donnelly and me approximately ten months ago. Baby Axel died because of the type of ultrasound performed. Baby Axel was a very wanted baby who was conceived in a fifth round of IVF. The pregnancy was high risk for the mother. The contributing factors were the failure to recognise and appreciate risk factors, failure to listen to Evonne, poor communication and inadequate documentation. I ask the Minister to have somebody in his Department work with Damien and Evonne to bring closure to this case as there is much hurt attached to it.

For all women listening in, the most important thing we would like is to ensure that we have timely access to ultrasound. Women's access to ultrasound should not be determined by geography. It should be in place right across the country.

For an expectant first time mother or a woman who is going in to have her second or third baby having had a bad experience, it is a frightening place to be. Ireland is not anywhere near top of the league when it comes to having a baby or having safe and dignified care. Women have taken a battering in this country over many years and particularly in the last couple of years. I am only three years in this House and we have been talking about symphysiotomy, CervicalCheck and abortion. We are consistently talking about women's reproductive issues, sometimes in a vacuum and sometimes in our little bubble. The message is similar right across the board. The standards of care fall way below what should be expected in a First World, developed and wealthy country. Services should be safe for women. They should feel safe when they go into a hospital. They should feel excited about the birth of their child, not worrying how the birth is going to go and how they will be treated. Many women fear going in a hospital in this country. We should be reaching the top international standards but we are not. We should ensure that mum and baby are cared for and that our care is woman-centred, that she is in control at all times and that what she wants in terms of her birthing experience is listened to.

As Deputy Rabbitte pointed out, it should not be a postcode lottery but very often it is. Some hospitals provide better maternity care than others. Women in rural areas are not getting the best care they could be getting. The national maternity strategy is most welcome but it has not really been acted on. There are many recommendations that still have not been actioned or delivered. Without proper funding and increased capacity, that maternity strategy is doomed to fail.

On infant mortality, Ireland ranks 15th in the OECD. Contrary to popular belief and to what has been uttered in this House, we are not top of the scoreboard where it comes to infant mortality. We have heard many horror stories over the years. The biggest issue facing women in this country when it comes to having a baby is scans first and foremost. In some areas, women can get better scans than in other areas. In my constituency of Mayo, getting an anomaly scan is really difficult. It has improved slightly but getting it at 20 weeks is still not guaranteed. Women may be waiting up to 25 weeks. At most, it should be 22 weeks. Going beyond that means those women are not getting the care they should be getting. It is 2019 and we are a wealthy country. There really is no excuse for it.

We are not providing the best consultant care we can provide. Women basically turn up and see whatever consultant is on that day. There is no consistency. For an expectant first time mum, it is very reassuring at least to expect to see the same doctor every time she goes to hospital. That should be facilitated. There is no reason it cannot be. Birthing facilities also leave an awful lot to be desired. There was an incident in my constituency where the very next day after giving birth, a woman was asked to sit in the chair beside her bed so they could clean and strip the bed for the next patient coming in. She was barely given 24 hours after the birth before she was asked to move to the chair beside her bed. Many people have referred to our maternity units as being a bit like a cattle mart or conveyor belt.

That is true.

Get them in, get them out, six to a room. Women cannot get any sleep because it is so noisy. The birthing facilities are those of a Third World country, not a First World country. We could go on. Given what women have been through in this country, it is very little to ask that we have proper birthing facilities, that women are not crammed in six to a room, that they can have consistency in the doctor they see, that they are respected and treated with dignity at all times, and that the consultants they see give them the best possible care. In order to do that, we need to fund the maternity strategy and increase capacity in our maternity hospitals.

I am pleased to get a few minutes to speak on this subject. Unfortunately, like a lot of debates, the time runs very short. This was the first maternity strategy and it was launched against the backdrop of many years of neglect of maternity services. The reality is that women should feel safe when they go into maternity services. The best outcomes should be achieved for both the women and the babies. One of the amazing things about the system is that when it has to find money, it finds it. We find money for compensation cases that maybe should never have arisen in the hospitals. Compensation will never undo the damage done, no matter how much money we pay. We need to make sure we have world-class services available in our maternity hospitals.

I have raised concerns about this matter in the House previously. Many cases in respect of which there has been a lot of public outrage afterwards arose as a result of the fact that services or facilities on offer or available in the relevant hospitals were inadequate and that staff were overworked. My colleagues have just outlined this in some detail.

I ask that the Minister finds the money and not offer excuses. Some years ago, a person contacted me looking for something from a business I was managing at the time. I have him an excuse and he gave a very simple answer, namely, "Éamon I rang you for the product you have, not for excuses." I put it to the Minister that we get all sorts of reason as to why things cannot happen. All we are looking for here today is quite simple. We are looking for the maternity strategy to be fully implemented so that a uniform service of the highest and safest world standard is available to everybody in all of the maternity hospitals in the State for mothers, mothers to be and infants who enter those services. This should include gynaecological services and so on. It would avoid the kinds of cases that have arisen all too frequently in recent years. I put it to the Minister that it is not a lot to ask. The Minister has found such money for other services. It can be found and I ask that the Minister goes to find it to implement this strategy now.

I welcome the opportunity to speak about our maternity services, to highlight the considerable progress made in recent years and the excellent work done by our front-line staff every day and night right across our maternity services and to outline the next steps we need to take.

Fianna Fáil will try to present this motion as some sort of policy development on its part. The reality is that it is a motion which reiterates Government policy; a Government that has actually prioritised maternity services, unlike when Fianna Fáil was on this side of the House. Fianna Fáil Governments, with all the bounty of a booming economy at their disposal during the Celtic tiger years, did not rebuild the National Maternity Hospital, Holles Street, the Coombe or the Rotunda. Nor did it set aside a single cent to do so under any capital plan. Fianna Fáil set up a HSE that did not have a women and infants health programme or a clinical director for such a programme. Fianna Fáil never had a national maternity strategy. It is quite remarkable and shocking that it was not until Fine Gael and Labour were in government and the current Taoiseach, Deputy Varadkar, was Minister for Health that we published the first ever national maternity strategy. When it came to holding a key referendum on women's reproductive rights and abortion last year, people like Deputy Lisa Chambers and others led on the issue but, sadly, 21 Fianna Fáil Deputies voted against allowing a referendum that would give women and the people of Ireland have their say. It is, therefore, difficult to trust that party when it comes to its newfound interest in maternity care, although that interest is welcome.

There has been a sustained and long-overdue focus on the development and improvement of our maternity services in recent years. Previously, these services did not receive the level of attention or investment they warranted, with deeply regrettable outcomes for women and babies in some instances, which Deputy Donnelly quite rightly outlined. These events are terrible for the women and families concerned and for the staff who work in our maternity services. We must always ensure that we care for them and learn from what happened.

At the same time, it is important to recognise that there are tens of thousands of positive, beautiful experiences across our maternity services every year. This care is delivered by exceptionally dedicated and talented people and I would like to put on the record that their work is very much recognised, appreciated and valued, not just by this Government and the Oireachtas but, most importantly, by the 80,000 women and families who access our maternity services in Ireland every year.

The national maternity strategy published in January 2016 maps out the future for maternity and neonatal care in Ireland. The aim of the strategy is to ensure that services will be safe, standardised, of high quality and offer an enhanced experience and more choice to women and their families. Together with the strategy, for the first time we also have HIQA’s national standards for safer better maternity services and the first ever bereavement care standards, providing the foundation on which we are building a service where women and their babies consistently receive safe, quality care, delivered with compassion and dignity.

With these developments, we are already well on the way to achieving the vision of the maternity strategy and I am pleased to outline the progress made to date for the benefit of the Deputies present. In 2017, the national women and infants health programme was established within our health service to lead the management, organisation and delivery of maternity, gynaecological and neonatal services across primary, community and acute care. The programme is charged with driving the implementation of the national maternity strategy. A priority for the programme, which is headed by Killian McGrane and Dr. Peter McKenna, since its establishment has been the safety and quality of the care provided to women and their babies, and considerable strides have been made to improve on these areas.

All 19 maternity units now publish maternity patient safety statements on a monthly basis, as recommended by the chief medical officer after the perinatal deaths in Portlaoise hospital. Directors of midwifery have been appointed in all but one hospital, providing crucial additional clinical governance, with recruitment at an advanced stage to fill one outstanding post. Quality and safety managers are being appointed to each hospital group, with several of those posts already in place and recruitment is ongoing for the remaining posts. Maternity specific serious incident management forums are being established across the hospital groups, with a number of these forums already operational. In addition, a maternity event review tool has been designed and is being trialled.

Significant progress has also been made in implementing the 35 recommendations outlined in the Walker report into maternity services at Portiuncula Hospital, about which Deputy Rabbitte spoke with such passion. I am happy to work with the Deputy on the issues she raised. As of March 2019, the implementation group confirmed that 95% of the recommendations were now complete or nearly completed, but of course we need to get that to 100%. All of these developments will help to ensure that our maternity services operate to the highest, safest standards and, crucially, that incidents and practices can be monitored and events escalated rapidly if the need arises.

The national maternity strategy recognises pregnancy and birth as a normal physiological process and rightly places priority on a woman’s choice. That is why significant efforts and resources have been invested in the expansion of midwife-led care, including the development of community midwifery teams. A total of 16 of the 19 maternity units now have a midwife-led, structured care pathway in place. A total of 15 are actively providing midwifery clinics off site where some are completely community based while many have a blended model of community and hospital-based care. The first alongside birth unit was opened in 2018 at University Maternity Hospital Limerick, adding to the centres already in operation in Drogheda and Cavan. Several units now also offer home-away-from-home services, providing midwife-led home-birth environments within the maternity hospital setting. I commend those midwives and doctors who have taken ownership of the strategy and who are championing it in their local services. Their hard work is ensuring that more women in our maternity services can avail of a wider choice of pregnancy and birthing experiences, as articulated in the strategy’s vision. It can no longer be doctor knows best; it has to be about the woman's choice and supporting her in that choice.

Another very significant service development is that of access to routine anomaly scanning, which is a very important issue. I have heard Deputies speak about this. The strategy is unambiguous about anomaly scanning, stipulating that all women must have equal access to standardised ultrasound services. Additional funding provided in 2018 facilitated approval for the recruitment of the 28 additional sonographers required to provide 100% access to such a service. To date, the targeted allocation of development funding has seen the number of hospitals and maternity units offering 100% access to 20-week anomaly scanning double, from seven in 2016 when I became the Minister for Health to 14 in 2019. It is envisaged that all 19 maternity units will offer 100% access to anomaly scanning by the end of this year. I know that all sides of the House agree this is a very significant improvement and an important development.

Spending on our maternity services has significantly increased over the last number of years. Development funding provided to date has been used to increase capacity through the recruitment of additional midwives, consultants, theatre staff, ultrasonographers and quality and safety managers. Since the strategy was launched there has been a significant increase in the numbers of clinical staff working in our maternity services, including 22 more wholetime equivalent, WTE, consultants and 165 more WTE nurse midwives compared with December 2015. This is 22 more consultants and 165 more midwives working in our maternity services over the last four years. When the birth rate is taken into account, we now have an improved staff to birth ratio in Ireland.

Deputies will be aware of the very significant investment the State is making in the new national maternity hospital at the St. Vincent’s University Hospital campus. This will be the single largest investment in maternity services ever made in the history of the State.

It is Government policy to co-locate all remaining maternity hospitals with adult acute services in order to provide optimal clinical outcomes for women and their babies. To that end the national development plan provides funding for the infrastructure to support implementation of the maternity strategy. Let me be clear, it is Government policy is to co-locate all remaining maternity hospitals with adult acute services in order to provide optimal clinical outcomes for women and their babies. To that end, the national development plan provides funding for the infrastructure to support implementation of the maternity strategy. Our development plan provides the funding to rebuild all four of these stand-alone maternity hospitals. This will facilitate the provision of an appropriate environment within all our maternity hospitals and units to enable the delivery of a modern, safe, quality service where the woman's need for privacy and dignity is respected. The Department is engaging with the National Maternity Hospital, Holles Street and St. Vincent's Healthcare Group to develop a legal framework to protect the State's significant investment in the new facility. While I note Deputy Donnelly's comments on the timeline for this, I also note his party Leader's parliamentary questions quite rightly asking that we get this legal framework right and protect the interests of the State and protect important ethical matters so that we can get this right for the women of Ireland and we are going to do that. It should also be noted that work commenced in February 2019 on the new pharmacy and the extension to the car park, which represents the first phase of the new national maternity hospital. Those works are under way on the site of St. Vincent's Hospital.

The value we place on the voice of the women who use our maternity services is central to that ongoing change taking place. The national maternity strategy is all the better for the 1,300 of such voices who were heard in its development. This was not a strategy written by a Department. It had the voices of 1,300 women who had used our maternity services, as well as the service user representatives on the strategy's steering group. We are continuing to listen and a national maternity care experience survey is being developed for launch in the first quarter of next year. We will extend the patient experience survey to the maternity hospitals. This will build on the success of the national patient experience survey and help inform the design and delivery of maternity services into the future. I reiterate my commitment to implementing the actions set out in the national maternity strategy and the Department will continue to support the national women and infants health programme in achieving those objectives during the remainder of 2019 and beyond.

I move amendment No. 1:

To delete all words after “Dáil Éireann:” and substitute the following:

“recognises:

— the need for Ireland’s maternity services to be as safe as possible for women and babies, including the need for women to be listened to and respected;

— the hard work, skill and dedication of all staff across Ireland who provide maternity services;

— the growing crisis in maternity care for reasons including:

— outdated and inadequate hospitals;

— limited diagnostics;

— poor staffing ratios;

— insufficient parental supports;

— wide geographic variations; and

— lack of community-based options for mothers;

— the deep concern these pressures are resulting in for current and expectant mothers and fathers; and

— the increased burn-out and stress for clinicians, together with a retention and recruitment crisis and chronic staff shortages;

notes:

— the publication of the National Maternity Strategy 2016-2026, Palliative Care for Children with Life-Limiting Conditions in Ireland – A National Policy by the Department of Health, the Health Service Executive’s (HSE) National Standards for Bereavement Care following Pregnancy Loss and Perinatal Death, and the 2014 Report on End-of-Life and Palliative Care in Ireland by the Joint Committee on Health and Children;

— the submission of the National Standards for Safer Better Maternity Services by the Health Information and Quality Authority (HIQA) to the Minister for Health;

— that the 2008 KPMG Independent Review of Maternity and Gynaecology Services in the Greater Dublin Area identified the need for maternity services to be co-located with adult acute services;

— the repeated announcements from 2013 onwards, including in the Capital Plan 2016-2021 and the National Maternity Strategy 2016-2026, that Dublin’s three maternity hospitals and Limerick’s would be relocated, with:

— the National Maternity Hospital to St. Vincent’s University Hospital campus;

— the Coombe Women and Infants University Hospital to the St. James’s campus (to happen in parallel with and be tri-located with the National Children’s Hospital);

— the Rotunda Hospital to the Connolly Hospital campus at Blanchardstown; and

— Limerick Maternity Hospital to the University Hospital Limerick campus;

— the lack of progress on these essential projects, including:

— on-going delays regarding the National Maternity Hospital; and

— no progress and no budget allocation to begin the relocation process for the other maternity hospitals;

further notes:

— the numerous reports into localised maternity care issues in recent years, including Portlaoise, Portiuncula, University Hospital Galway, Cavan, and Drogheda hospitals;

— the lack of progress in implementing various recommendations from these reports;

— the clinical, patient and political buy-in to the National Maternity Strategy 2016-2026, and the lack of implementation of that strategy, with no new development funding for it in 2019;

— the serious inequalities and absence of resources which exist within the HSE to provide services to children with life-limiting and complex medical needs, and to those under palliative care;

— that new-born screening services in this State only screen new-born babies for 8 conditions, whereas Britain screens for 9, Switzerland 13, Sweden 24, Portugal 25, and Italy 40;

— the lack of progress on numerous issues raised in recent years by midwives, including staffing ratios, working conditions and pay inequalities, with:

— just two midwifery-led units in place; and

— a shortfall of 200 midwives below the recommended safety-levels in the National Maternity Strategy 2016-2026;

— Ireland’s low-rate of obstetricians per capita, being the third lowest in the Organisation for Economic Cooperation and Development, and being further exacerbated by a high-level of unfilled posts; and

— the rise in State payments in compensation for incidents in maternity units, up from €4 million in 2007 to almost €120 million in 2017;

and calls for:

— a definitive timeframe and funding deployment for the relocation of the standalone maternity hospitals;

— progress to start in 2019 on all projects not yet commenced;

— a guarantee from Government that new public maternity hospitals will not have separate external or internal entrances, nor separate facilities within the hospitals, for private patients;

— the Government to ensure that the new National Maternity Hospital is built on the St. Vincent’s Hospital campus as quickly as possible, remains entirely within public ownership and has legally guaranteed independence from all non-medical influence in its clinical operations within the laws of the State;

— funding and a taskforce to implement the National Maternity Strategy 2016-2026, including choice around birth, types of antenatal care, access to anomaly scanning, breastfeeding, counselling services, public health, domestic violence supports and appropriate staffing levels;

— swift approval, dissemination and implementation of the National Maternity Standards for Safer Better Maternity Services;

— an active clinical programme for the development and review of clinical guidelines for maternity services;

— expansion of the new-born screening programme and guarantee that every child born in this State has the right to be screened at birth for any disease for which there is a viable treatment;

— an immediate statement of maternity services available at all sites, including prenatal screening, access to foetal medicine, counselling, genetic testing and laboratories being used;

— all maternity hospitals to have access to foetal anomaly screening, with the requisite staff and equipment;

— investment in community-based pathways to ensure choice for mothers;

— indemnity to cover practice nurses who give antenatal care;

— measures to address the chronic staff shortages, including ending pay disparity;

— the Government to work with nursing and medical unions in the recruitment and retention of medical staff so that all maternity hospitals meet the Birthrate Plus standard for midwifery staffing, as well as international standards for consultant obstetricians and gynaecologists;

— the implementation of the recommendations of the 2014 Report on End-of-Life and Palliative Care in Ireland by the Joint Committee on Health and Children, prioritising those parts relating to care for children with life limiting conditions; and

— investment in a national foetal magnetic resonance imaging (MRI) programme and bereavement care.”

There is one project under way.

The facility has not been built. As I said in referring to the tit for tat, the women watching this debate will not thank us for that. No one will disagree when I say I have raised the maternity services issue consistently in this Chamber since I was elected. In 2017 this House passed a Sinn Féin motion on maternity services which called for solutions to pressing matters affecting the service. I would love to be able to say that the calls included in that motion which was not opposed have been implemented but this is not the case. Many of the areas for improvement outlined that night in May 2017 still exist, and two years later they are again outlined in this motion. Women are still being denied a basic 20-week anomaly scan. While I absolutely welcome the commitment given by the Minister that they will have access to such scans by the end of the year, I am somewhat sceptical not on the basis of any ideological position that I have but merely on a quick glance at the record because there have been many false dawns on this issue. It is absolutely essential that the 20-week anomaly scan is rolled out. It is an essential screening tool.

Every time I have asked a question about this I have been told it is offered where clinically indicated to which I have replied how would someone know it was clinically indicated if the scan is not done. The Minister's commitment is welcome. We will hold him to it because it is a very essential and very basic service.

We have included in this amendment reference to the newborn screening programme. I was compelled to include this having met with Les Martin, an inspiring young father who is campaigning to improve our newborn screening programme. I know Deputy Donnelly and the Minister know Mr. Martin, as does my colleague Deputy Brady, because this young man is from Wicklow. I want to raise some of the issues he has spoken about and speak to the solutions he has also proposed for improving our newborn screening programme and save lives. Newborn screening services in this State screen newborn babies for only eight conditions, whereas Britain screens for nine, Switzerland 13, Sweden 24, Portugal 25 and Italy 40. The failure to screen babies in Ireland to a higher standard has had a devastating effect on many families in the State, including the Martin family. The Minister is aware of this but it did not have to be this way. Les has gone to great lengths to highlight a solution. He presented this a briefing in the audiovisual room organised by Teachta Brady some weeks ago and he outlined what could be done and what we need to do. We need to reform and expand the newborn screening programme and guarantee that every child born in this State has the right to be screened at birth for any disease for which there is a viable treatment. This is what was done in Italy when a law was passed there to ensure that every Italian citizen is entitled by right to be screened at birth for any disease for which there is a viable treatment. It is a sort of 'if the technology and research are there and back it up we should use it' approach. The expansion of the programme would not be a huge cost, but it would have a huge impact and benefit for families and babies, and it would in the long run save the State millions of euro.

Almost daily here we are reminded of the recruitment and retention crisis affecting the health service. The motion outlines how we have just two midwife-led units in place, how we have a shortfall of 200 midwives below the recommended safety levels in the National Maternity Strategy 2016-2026 and how the number of obstetricians per capita is the third lowest in the OECD. The Minister cannot stand over that situation. It is not tenable and it is not right. The health service needs to do more to help women with disabilities when they are planning a family or are pregnant. Where a woman has a disability which makes becoming pregnant more difficult or carrying a child to birth more difficult, specialist medical help should be provided. This care should be continuously provided from family planning stage all the way through to post-natal care.

I included a reference to the new national maternity hospital in my amendment because I want there to be no equivocation. This House agreed in 2017 that the hospital would be kept in State ownership and the people providing the service will have the ability to deliver those services free from any non-medical interference. I ask the Minister to reaffirm that commitment and provide an assurance that the hospital will be delivered and operate along these lines, because there is still some confusion among the public.

I am asked about this regularly. We really need to hear completely and unequivocally that the hospital will operate free from any non-medical interference. During the campaign for the repeal of the eighth amendment, there was much discussion about women's health and healthcare needs. This was very welcome but the fine words contrast with the lived experience of women who use our maternity services. The standards of care fall well below those which women should be entitled to expect. The postcode lottery is not acceptable and there is no reason an expectant mother in Mayo or Laois or anywhere else should expect to get less from the maternity services than an expectant mam in Cork, Dublin or Waterford. We have a strategy. We need funding and a commitment that the strategy will be implemented. Women and babies deserve much more than fine words.

To be a bit parochial for a moment, the Rotunda Hospital is back in the headlines. It is a fantastic hospital and many of the babies in my constituency travelled there to be born but it is an old building.

It is no longer fit for purpose in many parts. It requires a small investment and yet we are told repeatedly this will be put off because at some stage some hospital is about to be built. In the here and now, however, mothers from Fingal are having to travel into the Rotunda Hospital to deal with a hospital that is not fit for purpose in parts. We are not talking about a massive investment but the Government cannot continue to put it off and say there is no need to invest because a new hospital will be built. At this stage, a small investment is required for the neonatal unit in the Rotunda Hospital. I know the Minister is aware that there were some difficulties there, which have been back in the news. The last thing the men and women who work there want to be talking about are these difficulties. They went into these jobs to be able to bring babies into the world, not to constantly have to grapple for resources. Women and expectant mothers in my constituency deserve a better infrastructure than the one they are offered at the moment.

I welcome the opportunity to speak on the Fianna Fáil motion tonight but I also want to call for support for the Sinn Féin amendment because, in fairness, it is positive and constructive.

One issue which can be overlooked when talking about maternal health is mental health. For too long, the mental health of pregnant women and new mothers was treated with little concern. While we recognise the problems, which about 11,000 Irish women experience every year, we have done little to provide supports and solutions for them. The biological, psychological and social impacts that pregnancy and childbirth can have on women should be every bit as much of a concern for our health services as the physical and medical responses provided already. Women, during and after pregnancy, need diagnostic and treatment services which ensure their mental well-being. Depression and anxiety, in particular, occur during and after pregnancy and this cannot be dismissed.

In the Six Counties, a regional perinatal mental healthcare pathway has been in place since 2012. The HSE has published a plan for specialist perinatal mental health services in 2017 but more needs to be done to address this. In research, women describe feeling isolated and without support. The restructuring of reproductive healthcare as a woman centred model is crucial to ensuring that depression related to pregnancy and childbirth is treated seriously. Screening and care should be provided to women during and after pregnancy to the standards of international best practice.

We need to see the development of perinatal and postnatal mental health services, which provide perinatal screening for depressive and psychotic symptoms at the first, second and fourth month, with a minimum of one screening per trimester. We need perinatal mental health units working together, located North and South and a postnatal screening model through GPs and paediatricians with screenings taking place bi-monthly, or alternatively, in conjunction with the immunisation schedule. We also need to develop educational and supportive materials for the woman and her partner, if applicable, to better identify issues early on, and to prevent issues arising through self-care. Free counselling sessions should be provided to women after pregnancy and we should ensure all women receive home visits from an appropriate professional within the first three months after pregnancy. We need a policy that places the health of the woman as the primary consideration at all times in choosing any treatment.

I ask Members again to support the positive Sinn Féin amendment and to vote for this worthwhile motion.

Two months ago, I met with Les Martin and I know the Minister knows Les, Lynda and the family. He is a constituent of ours and of Deputy Donnelly. He is a husband and a father to three young children. Two years ago, both of Les and Lynda's sons, Cathal and Ciarán, were diagnosed with a rare genetic terminal condition. At the time of diagnosis, Cathal was almost two years old and, unfortunately, it was already too late to treat him. He was expected to live to the age of five. He turned five last month. Ciarán has been engaging in a medical trial in Italy and that is expected to save his life.

The delay in diagnosis is what has Cathal's young life on a knife edge, as Les has said himself. If Ireland's newborn screening programme met international best practice, Cathal and his family would not be in this most cruel position, nor would the 50 or so other Irish families that are needlessly being destroyed every year because of our failure to expand our screening programme. We have an opportunity to make sure no other young life is destroyed and that no other family will have to face this immeasurable suffering by simply expanding our newborn screening programme.

At birth we screen for only eight conditions, whereas many of our EU counterparts go way beyond this. Italy tests for 40, Portugal tests for 25 and Sweden tests for 24. I want to take this opportunity to commend Les, not to plámás him or anything like that because I know he would not appreciate that but I commend him on stepping up selflessly and taking action by doing the job of this House and bringing forward the solution in expanding our newborn screening programme. He has handed us the solution based on the successful model in Italy. I know the Minister has looked at it and he has spoken with some people from Italy who are engaged on this. We need to take that solution and we need to make it happen here in this State. We can do better and we need to do better, for Cathal, for his family and for every newborn brought into this world.

That means supporting our amendment to this motion here this evening, to ensure that newborn screening is expanded and to take action to ensure this programme can be extended this year. We need to do it this year and we also need to guarantee that every child born in this State has the right to be screened at birth for any disease for which there is a viable treatment. If that needs legislation, we need to ensure that legislation is brought forward immediately. The costs are minuscule for rolling out this. We are only looking at €50 per child born. Those are the costs I have been given.

I am asking Deputy Donnelly and Fianna Fáil to accept this amendment and I am asking the Government to support the amendment and to support the motion because we owe it to the Martin family and to all the families out there that this State has let down by not expanding our newborn screening programme.

The Minister and I have spoken at length on this topic many times. When it comes to various different areas of health and all the strategies that are continuously put forward, this is pound for pound the best strategy that has been published in any area in healthcare. It is one of the best strategies I have seen written down and it is very comprehensive. The Minister will see it is about the implementation of the strategy and that is the real reason we are talking here tonight. It talks so much about providing a safe, high quality service that meets all women's needs. It states that women should be, "Placed at the centre of all services, and are treated with dignity, respect and compassion; parents are supported before, during and after the pregnancy." The strategy states that there are four strategic priorities, which are worth reading. Those priorities are as follows:

1. A Health and Wellbeing approach is adopted to ensure the babies get the best start in life. Mothers and families are supported and empowered to improve their own health and wellbeing;

2. Women have access to safe, high quality, nationally consistent [which is a critical phrase], woman-centred maternity care;

3. Pregnancy and birth is recognised as a normal physiological process, and insofar as it is safe to do so, a woman’s choice is facilitated [which brings us back to the community services];

4. Maternity services are appropriately resourced, underpinned by strong and effective leadership, management and governance arrangements, and delivered by a skilled and competent workforce, in partnership with women.

Those four points encapsulate this whole debate and everything we have heard here tonight because, along with that, we have a situation - a previous speaker made reference to a specific case of this - where for various different reasons, pregnancies are becoming more complex.

While there are better survival rates and more babies are being born, statistics show there are far more caesarean sections than 20 or 30 years ago, the proportion of low birth weight babies and pre-term births is increasing and breastfeeding rates remain low. There are a number of new challenges. The service needs to be continuously resourced but also changed. When children come along, it is an opportunity for many women and families to change life choices. The broader issue needs to be addressed.

The strategy is essential and needs to be supported. I wish to put a number of issues and questions to the Minister in respect of where we are after three years. It is a ten-year plan and we are three years into it. I have spoken to many people in the area and all of them feel the service is severely underfunded. They feel that how it has been treated is in some ways tokenistic and that they have been let down because of overruns on various capital and current issues. The lack of a task force to implement the service in a detailed way needs to be addressed. People are shouting from the rooftops about the need for something like that with teeth to push the Minister and whoever replaces him - if somebody replaces him in the coming years. The requirement for multi-annual funding to ensure that the services can be provided is obvious. According to the Department's figures, the funding provided directly for the implementation of the plan - €4 million - is very low. Have the positions that need to be filled even to start the process of implementation and keep it going been filled? It has been repeatedly said to me that no new developments in the future funding have recently been announced. There are 77 recommendations, all of which are important, in a range of areas I outlined, to fulfil the objectives of the strategy but there is no way they will be implemented within the ten-year timeframe because we are already well behind. We need to ring-fence funding, catch up and ensure we can provide the services in the future, with the required human resources.

Much has been said about staffing issues. I am not sure the Minister or the Government understands the situation. There is a serious issue with the number of obstetricians, midwives and a whole range of other disciplines. The report on the strategy stated the number of consultant obstetricians would be doubled within ten years but that will not happen. The requirement was to hire a range of midwives in various parts of the country but that will not happen. In diagnostics, specialist personnel are required to read the various diagnostic equipment, which evolves all the time, but that simply will not happen. Although I fully accept the Minister's bona fides in respect of wanting to provide diagnostic services throughout the country, it simply will not happen, or at least not at the pace required. That is discriminatory because one should have access to the same services throughout the country, as has been raised with me a considerable number of times.

I have a concern about perinatal services, which I have raised with the Minister numerous times. It is a hobby horse of mine. I have seen various reports and figures on issues of mental health for women who are pregnant, or in post-pregnancy or pre-pregnancy. The lack of services, particularly in psychiatry, is a real issue and an area where there is deep concern. I know this because it has been raised with me. Which hospitals in the country have the best services, the highest rate of services and the greatest range of services? The Minister might revert to the House with a response. In diagnostics, which hospitals have the highest rate of neonatal brain injury? While the Minister may not have those figures on hand, he might follow up with them later.

I come from the mid-west. A new hospital is required in Limerick and is provided for in the strategy. I have raised directly with the Minister that €5 million is required for the design of the hospital. If the €5 million cannot be found, no hospital will be built any time soon. The Minister cannot find the €5 million, however, and we are a year behind. I was born in the hospital, as were my brother and children. The staff operating in that building are amazing, incredible people but the services need to be moved to the university hospital.

I am glad previous speakers mentioned the new national maternity hospital. Two years ago, when the issue blew up, there was a notification from the Sisters of Charity that the relationship would change and that the hospital's ownership would be transferred from a charity to a company. On the charities register of the Charities Regulator, however, where is the company? I have a specific question for the Minister and I need a direct answer tonight. What organisation, company or charity - whichever phrase the Minister wants to use - currently exists, on 19 June 2019? How and where is it registered for the transfer of the ownership we were told about two years ago?

In the context of the debate, people will vividly remember Joe Duffy's series of programmes in April on the experiences of women in maternity hospitals. It received responses from many hundreds of women who contacted the show and had negative and often harrowing experiences of giving birth in Irish hospitals. It was one of the largest responses the "Liveline" show had ever had, with many women wanting to share their experience publicly. We must ask ourselves why the experiences have been so poor for so many women. It is not just because the midwifery or nursing staff in the ward with them at the time treated them badly, or a combination of that and a failure of resources and services provided by the State, or even the deeper issue of the paternalistic delivery of services. What is known as active management, which it was decided in the 1960s would be pursued, has positive outcomes but, importantly, it also means the labour process is sped up by breaking the waters and using synthetic hormones. By its nature, it leads to more interventions during labour and results in a highly prescriptive and medicalised birth process. It can also leave women feeling ignored, disrespected and disempowered. Many women make the point that they feel safer and better and have better outcomes during birth if the team who cares for them is midwifery led.

The problem also stems from the failure of the Government and previous Governments to staff and resource properly maternity services. From the recent nurses' strike, we know there is a crisis in the recruitment and retention of nurses and midwives but I am unsure whether the deal that ended the strike will result in an improvement in that regard.

There was a recent tragic case in Cork where a mother and child died. This highlights how chronically under-staffed and over-stressed are much of our maternity services. This is not to claim that tragedy directly related to the staffing issue but the staffing issue was very clearly highlighted as, that evening 31 patients on a labour ward were being cared for by three nurses, which is really stretching the resources. These ratios, however, are not confined to that case and are systemic across maternity and other services. Again, during the recent strike, many of us who spoke to nurses and midwives on the picket lines were struck by the fact that what distressed them more than the lack of pay parity and the inequality between their grades was the danger they had to live with putting their patients in on a daily basis as a direct result of the lack of staff and resources.

The core problem many women face is structural and deep and, in many cases, goes back to an attack on public services and on nurses by this and other Governments. Addressing these issues in isolation is impossible as they are embedded in the general undermining of our health service through ongoing privatisation and the building of a two-tier health system. In that context, I was struck by part of the motion and the amendment, which calls for a guarantee that the new maternity hospital will not have separate external or internal entrances, nor separate facilities within hospitals. This issue, I would argue, is very important. It is not about maternity hospitals having separate entrances and exits for private or public, but the fact we have a two-tier health service, with private and public mixed together. It is a fact the ratio of nurses and midwives and access to essential services and resources often differ between these two health services. The fact we have privatised the health system and continue to do so is very disturbing. It needs further discussion and further opposition within this House.

There is a shortfall of hundreds of midwives in this country between what is needed, what is best practice and what is reality. The motion makes reference to 200 but I believe the real figure is closer to 300. At the same time, women are tending to have children at a later age than was the case in the past, including at a later age for a first child. The combination of these two things is putting an enormous strain on maternity services.

I want to look at this from the point of view of my local hospital, Cork University Maternity Hospital, CUMH. There are currently 30 vacancies for midwives at CUMH. The result is that in the postnatal ward, according to a midwife to whom I spoke before I came to the Chamber, where there should be six midwives on the ward per day, it is not uncommon for the number to be three or four. There is a certain irony here in that one of the factors in the vacancies is that nurses are taking maternity leave and are not being replaced in the way they should be. CUMH is the lead maternity hospital in the region, meaning it gets many referrals, including referrals of some of the most complicated cases. These midwives and that maternity service are trying to deal with this situation from a position of under-staffing.

How do we attract more midwives into our health services? It is not as simple as getting more nurses in from the European Union or more midwives from Asia, and so on. In many countries, there is a qualification which is for both nursing and midwifery whereas, in the Irish health service, there is a specific midwifery qualification. Therefore, not every country can send staff to fill the gaps. While that is the norm in Italy and some other countries, it is not the norm in the majority of countries. Therefore, there are strict limits on the number of midwives who can come into the country to work in our health service at the moment. We need more nurses choosing to have midwifery qualifications and getting involved in midwifery, and more students being trained and coming through the system.

What is holding things back? There are many reasons for things being held back but first and foremost among them is the question of the relatively low pay and the poor and stressful conditions. Midwives took to the picket lines with their nursing colleagues earlier this year to address the situation and a deal was done at the end of that dispute. It was a deal which represented a gain for nurses and midwives but it fell short of the original aim of the strike and what many nurses and midwives aspired to, and many of them would agree with that point. I believe that deal is not going to get to the root cause of the problem - the issues with pay and conditions - and, therefore, the root cause of the problem remains. That is something which will resurface very clearly over the next months and years and the issue will remain to be addressed. If the Government and the Department are not prepared to addresses it, the question of campaigning action, including industrial action, by nurses and midwives will once again come onto the agenda. This is a key issue that will not go away.

A few weeks ago, on "Liveline", many brave women spoke out about their harrowing experiences of Ireland’s maternity services, past and present, and how they had felt let down by the system. No woman should ever have to suffer in such a manner and what happened should never be allowed to happen again. We need to work towards making our maternity care safer. We are fortunate to have some the world’s best nurses and midwives here in Ireland and these staff work tirelessly for the patients for whom they are caring.

There is a shortfall of 200 midwives below the recommended safety levels in the national maternity strategy 2016-2026. It is time the Government invested more in nurses and midwifery staff and addressed the chronic staff shortages, along with the staff retention and recruitment crisis. The Government has the opportunity to work with the maternity staff to provide a world class maternity service to Irish women; it just needs to take the bull by the horns and take action.

We need to see more investment in community-based maternity services for woman. I welcome that, in my own constituency area of west Cork, Bantry General Hospital holds antenatal clinics on a fortnightly basis. However, I still feel that Bantry General Hospital, with the Government's support, could be used to offer more maternity services to women. It is scandalous that it closed the maternity service at Bantry General Hospital some years ago. The mindset of the Government at that time must have been at negative zero, as it always is in regard to west Cork. Many people living near to a maternity hospital may not realise the real fear for people who are living in areas such as Castletownbere, Kilcrohane in the Sheep's Head peninsula, Mizen Head, Schull or Goleen. It is a two to three hour journey on a good day to their local maternity hospital. Imagine how dangerous this journey would be in bad or icy weather. Bantry General Hospital is much closer and if more maternity services were offered there, imagine the peace of mind it would offer to so many women and families living in these isolated areas.

I am glad to have the opportunity to speak on this very important motion. It is grand to be talking about something as natural as this. When we were talking about babies last year, it was talk about killing people but this is better, proper and natural. The birth of a baby is a very important thing to a mother and a family. We need to ensure we have a safe, modern and world class service for mothers and babies.

I commend the tremendous maternity services at Tralee General Hospital and I congratulate the doctors, nurses and midwives who provide those services. They are exceptionally good, as are maternity services at Cork University Hospital. For many people in County Kerry, Cork University Hospital is closer than hospitals in Kerry.

As stated by Deputy Michael Collins, it has to be recognised that many parts of Kerry are long distances from Tralee General Hospital. Cuhig in Lauragh on the boundary of Ardgroom in the Bearhaven, Valentia Island and pockets of Glenmore and the Black Valley are approximately an hour and a half away from the maternity hospital. It should be possible for a pregnant woman who requires emergency services to access them in Dingle Community Hospital, Kenmare Community Hospital or Killarney Community Hospital. There must be emergency services available in these hospitals to allow for the delivery of a baby sooner than the journey to Tralee General Hospital would allow for the baby to be born safely.

It is important that we have a world class maternity service. We are appealing to the Minister of State, Deputy Catherine Byrne, and the Government to ensure maternity services throughout the country, including in Kerry and Cork, are modern and world class. Our babies are our future and it is vital they are born safe and well for the well-being of our communities.

I am happy to have the opportunity to speak on this motion. I accept the need to support our maternity services and the staff who perform heroic work against all the odds. South Tipperary General Hospital, known to most people as St. Joseph's in Clonmel, is the hospital where all of my children were born. Six of my grandchildren were also recently safely delivered there. The staff of the maternity and other wards are tremendous and dedicated. Maternity services at Cork University Hospital, where my daughter was cared for, are exceptional as well. I salute them for the work they do under enormous pressure most of the time. What I do not accept is the credibility of Fianna Fáil on this issue. We have seen this recently in terms of the tragic case of the baby who was misdiagnosed and died at Holles Street hospital. Deputy Stephen Donnelly came out and said that we must investigate if there are existing dangers in the service. He already knew the answer. As I understand it, at a meeting of the Joint Committee on Health on Wednesday, 19 September 2018, Dr. Peter Boylan-----

I ask the Deputy to desist from naming people.

He has already given testament to the committee.

He may well have done so, but this is the House.

At a meeting of the Joint Committee on Health on Wednesday, 19 September 2018, the doctor explicitly told Deputy Stephen Donnelly that the lack of MRI scanning services could lead to the termination of a child who may not have had a fatal condition. I reiterate that he said the lack of services "could lead" to the termination of a child who may not actually have had a fatal condition. His exact words in response to a question from Deputy Stephen Donnelly were as follows:

The MRI machine in the National Maternity Hospital, with some jiggling around, could possibly be a national centre for referral to clarify the diagnosis for women and pregnancies where there are foetal abnormalities. The consequences of getting it wrong are serious. We could end up with a termination done for a condition that is not fatal or vice versa.

As has been said by other commentators, this makes it absolutely clear that there were warnings that the roll-out of abortion services in this State to accord with a political rather than a clinical deadline was capable of ending the lives of unborn children deemed to have a fatal condition, but who did not actually have such a condition. The clamour and the rush was political not medical. This so-called service has placed additional and severe pressure on our maternity services at a time when the Master of the Rotunda says premature babies do not even have access to appropriate levels of care in our maternity units. It is fine to be crying wolf now. The warnings were given to any of the members on the health committee who chose to listen. We all felt that the man leading the campaign and giving the medical advice, and was saluted afterwards for doing so, gave us those warnings. It is on the record of the House. It is hypocrisy of the highest order for this motion to come before the House when we have had, unfortunately, a tragic death of a baby, and maybe many more.

I am sharing time with Deputy Catherine Martin.

Is that agreed? Agreed.

In the few minutes I have available to me I want to again raise the issue of the long promised and much needed national maternity hospital to replace Holles Street hospital. This facility has been promised for some time. In 2012, the then Minister for Health, now Senator James Reilly, announced the move to the campus at St. Vincent's. At that stage, it seemed that none of the detail had been worked out. It was a political announcement and very much seen as such. We waited some time to get further detail on it. Approximately two years ago, the issue came to the fore again and concern was raised because it was not clear how a very valuable asset, estimated to cost approximately €350 million, could be developed on the grounds of what was essentially a private campus owned by St. Vincent's Healthcare Group. When this information became publicly known there was an outcry about it. The idea of the State handing over such a valuable asset to private interests was abhorrent to most people and there was considerable controversy about it at the time.

The other issue that was raised on several occasions was the question of the ethos that would govern the new national maternity hospital. There was a lot of concern expressed about the proposals to establish a board which would, in effect, give controlling interest to St. Vincent's Healthcare Group, which is a denominational organisation. Most people felt that it would be entirely inappropriate for a religious body to have control of a national maternity hospital because of all of the implications of that in terms of the type of services that would be provided and also because of the record of St. Vincent's Healthcare Group in respect of it being governed by a Catholic ethos and the level and type of services being provided being constrained as a result of that. Most people were strongly of the view that it would unacceptable that this situation would apply in regard to a new national maternity hospital and that there would be any question of the services that are legally available in this State not being available in a new national maternity hospital. This issue came to the fore and there was considerable controversy around it. The Minister for Health, Deputy Harris, battled this and set up different groups to examine it and looked to different ways of squaring that circle but he never really came to a conclusion about it.

On the eve of Christmas six months ago, the Minister made an announcement that agreement in principle had been reached with St. Vincent's Healthcare Group. The nuns were to be withdrawn from the board, a new company was to be established and a new management company was to be established in regard to the new national maternity hospital. It has been six months since the Minister offered the steadfast assurances that the investment of the State in the new national maternity hospital would be protected and its clinical and operational independence guaranteed. Last December, in an eve of Christmas announcement the Minister approved the contract for the first phase of construction at the hospital site to proceed. He told us then that agreement in principle had been reached with St. Vincent's Healthcare Group to allow the State to retain ownership of the new facility through a 99 year lease.

We were also informed that a suite of legal documents to give effect to this agreement would be finalised in the new year. We are now halfway through the year and we are still none the wiser as to the legal arrangements for the ownership and control of the hospital, the project relating to which the State is funding to the tune of €350 million. The Minister has repeatedly stated that he is confident that the new hospital will be clinically and operationally independent. It is impossible to see how that can be the case. We know that all kinds of approvals are required from the Vatican for that to happen and that none of those approaches have been made yet. I do not believe the Minister. I do not believe that this can happen in a way that is acceptable to the public. The Minister needs to come clean on the matter.

Tá an Comhaontas Glas sásta tacaíocht a thabhairt don rún seo. I commend Deputy Donnelly on tabling this motion, which the Green Party is happy to. Something I have heard repeatedly from women who have used our maternity services is that they were surprised by their lack of choice in birth plans, from a midwife-led approach to home birthing. The support options simply are not there for most people. This is backed up by research conducted by the Association for Improvements in the Maternity Services in 2015 which found that only 5.5% of women had the option of midwife-led care available. We need to ensure that expectant mothers are comfortable and properly cared for. To do this, we need to properly resource our maternity services, especially community-based ones as called for in this motion.

We must also look at our maternity services in the context of women's healthcare as a whole. I am pleased that the motion notes the need for women to be listened to and respected. That is key. We have seen women hurt time and time again with regard to healthcare provision in this country, including with the CervicalCheck scandal, the practice of symphysiotomy, damage from vaginal mesh and a long list of other issues. I would hazard a guess that most of us in this Chamber know someone who has endometriosis, a condition that is estimated to affect one in ten women. However, several studies point to a diagnostic delay in treating endometriosis. One reason cited for this is the normalisation of the symptoms and the diminishment of the pain felt. This and the other issues in women's healthcare are symptomatic of a wider problem, wherein women's voices, choices and experiences are all too often overlooked, undervalued or wilfully ignored. It is a harder task but if we want to ensure that women are truly at the centre of maternity care, we need to listen carefully to the experiences of women and enact care guidelines that take women's voices seriously.

One thing which is not explicitly outlined in this motion which needs to be addressed is the challenge facing migrant women within our maternity services. According to the second report of the confidential maternal death inquiry, women born outside of Ireland accounted for 39% of all maternal deaths between 2009 and 2012 despite this demographic only accounting for 24% of all women giving birth. We need to ensure that there is true equity of service for all women in maternity care. It is particularly important that this motion calls for timeframes for implementation of funding, resourcing and strategies. A recurring theme across the health service is that consultations are held and strategies are drafted but no timelines are stipulated and no funding streams are identified. We know what staffing we need. We often know what the challenges are. We now need action from Government. This is not particular to maternity care. It is in mental health care, primary healthcare and emergency healthcare, across the board. We do not need more documents on shelves gathering dust. We need resources on the ground.

I thank my colleague, Deputy Donnelly, for doing so much work on maternity services and on bringing this issue to the fore. The conversation in respect of it has to happen. As a mother of three, I am delighted to be able to discuss this issue.

The provision of accessible, safe and high-quality maternity services to all mothers and babies, regardless of where they live, must be a core objective of public health policy. Our national maternity infrastructure is under strain and needs serious review. As a mother of three, I am aware that childbirth is the most natural process in the world but that it can prove more difficult for some mothers. In my own case, of three induced births due to complications, I never had the mad rush to the maternity hospital or the danger of giving birth in a car or, as we heard recently, on a train that some other mothers might have endured. A bad experience during childbirth can have very serious side-effects, including depression, anxiety and panic attacks. It can also lead to a mother deciding not to have any more children, being traumatised and in some cases suffering extraordinary pain.

In April, hundreds of women shared traumatic childbirth stories on RTÉ's "Liveline" programme over a two week period, which led the HSE to apologise, stating:

The HSE apologises to those women where our service has failed to meet their expectations. We also apologise that women have felt compelled to ring RTÉ to have their concerns heard. This should not happen.

Over a fortnight, many women had taken to the national airwaves to share their stories of childbirth. The Minister of State may have heard some of them. They did not make for easy listening. The stories detailed how many of the women were left traumatised by the experience in some Irish hospitals and how they suffered extraordinary pain in some cases. Other women spoke about an inappropriate attitude they experienced at the hands of consultants, nurses and midwives during labour. That was not my experience. I have three children and there were times during the births of all three that I felt that I would not have got through it except for the fantastic staff. RTÉ's "Liveline" programme was inundated with phone calls from women who wanted to share their experience of Irish maternity services, both historical and recent. It struck me that there were so many recent cases. This is 2019 and I heard many new mothers, young women, who felt that the only way to express what they went through was to take to the airwaves. The powerful accounts shared by the women document a litany of concerns, with the women telling broadcaster Joe Duffy that the concerns they raised with medical staff were ignored.

While some of the cases related to issues that occurred many years ago, some stories were from maternity hospitals just a few weeks ago. Another caller said she told hospital staff that she could feel her baby was coming. The woman said the staff were washing the floor and said her baby was not on the way. The caller said she had to get her husband to help her on to the bed, and in a matter of ten minutes, her baby was born. She stated that she gave birth in the full view of everyone in the prenatal ward and was in complete shock. I have taken this angle because I was struck by the number of women who simply want to be listened to and to have a woman-centred approach to care.

Voice and choice are the key words here. Unfortunately, choice if one is living in a rural area is not always possible with regard to home births, midwife-led births and water births. However, the voice of the mother who carries the baby for 40 weeks and who goes through labour must be absolutely accepted and respected. When there are complications, birth plans go out the window and the clinicians, the gynaecologists and the midwifes must make split second decisions. However, normally, this positive, beautiful experience of bringing a baby into the world should be coupled with the best possible services and the best possible care.

I support the motion. I do not usually get into arguments or disagreements with people around here because I think we all have to work for the common good. That said, I was somewhat taken aback by the Minister attack on Fianna Fáil. My party is doing the right thing for the right reason. I acknowledge the work that Deputies Donnelly and Lisa Chambers and many members of the party have done in support of this motion. The provision of an acceptable, safe, high-quality maternity service to all mothers and babies, regardless of where they live, must be a core objective of public health policy.

It is clear that our national maternity infrastructure is under strain and needs serious review and investment. That is the purpose of the motion proposed by Fianna Fáil, which gets the support of most of the House. The failure to fund any new developments in the national maternity strategy in 2019 is a matter of great concern.

The Minister referred to various failures in previous years but if he was to look at his own tenure and the past nine years of a Fine Gael-led Government he would see that a significant number of problems have arisen in the system. That is the reason we are so concerned and why we want investment in the programme. Figures provided to Fianna Fáil last year showed that the State paid out almost €120 million in compensation in 2017 for incidents that occurred in maternity units. Since 2007 there has been a tenfold increase in claims and a thirtyfold increase in payments. Given the many high profile incidents in maternity units in that time, it is hardly surprising to see such a significant increase. Nonetheless, it brings home the price of error in the health service and underscores the need for standards and vigilance. It is in everybody's interests that we have those standards and that we have vigilance. The total awarded in 2017 at €120 million is a very significant outlay. Let us bear in mind that the HSE service plan for 2017 committed €81.3 million for the expansion of existing services or the development of new services. This is about having a proper and safe environment. So many young mothers have told me they are worried about going into a maternity unit. That should not be the way it is. Women should feel safe and secure in maternity units. I do not blame staff; I blame the lack of proper conditions and facilities. There are not enough staff on duty. Staff are not being appointed to fill positions. Deputy Rabbitte referred to a hospital in my constituency - Portiuncula University Hospital - which has been crying out for an accident and emergency unit for so long but it cannot be funded. The accident and emergency unit is vital as well in terms of the maternity services. This motion is about doing the right thing and having a proper service that people respect and feel comfortable accessing. We owe it to citizens, in particular young mothers and babies, to do that.

In concluding, Deputy Eugene Murphy said we all want to do the right thing for everybody, in particular women and their husbands and families, in maternity hospitals and other hospitals. It is important to remember that we have wonderful services in maternity hospitals and many extremely dedicated people from the top down.

On behalf of the Minister, Deputy Harris, I thank Deputies for their contributions this evening. It is encouraging to note that across the House there is a shared and sincere interest in the development and improvement of maternity hospitals, as well as an ongoing appreciation of the importance of implementing the national maternity strategy. It is important that we have all taken the opportunity to recognise the hard work, skill and dedication of those who deliver maternity care every day in hospitals right across the country. It is their passion and, indeed their compassion, that makes a difference to thousands of women and families at a joyous but vulnerable time in their lives.

As noted, in recent years, and in particular since the maternity strategy was launched in 2016, unprecedented attention has been focused on the development of maternity services. That focus is beginning to bear fruit, due in no small part to the dedication and skill of the talented people who deliver maternity services every day. It is also due to the increased and sustained focus that maternity services have received from the Government, including the additional funding we have provided, year-on-year, to ensure that those developments and improvements can take place. I believe that even one negative experience in our maternity services is one too many, and it is important that we recognise how difficult these events can be for the women and families concerned.

Both the Minister for Health and I firmly believe that implementing the national maternity strategy is the best way to reduce the negative experiences and also the best way to deliver the safe, quality and compassionate maternity service that the women of Ireland expect and deserve. In that regard, much has already been done to implement the strategy, and the progress made is both considerable and encouraging. As a result of the work undertaken to date, more women can now avail of the greater choice recommended by the strategy. The expansion of community midwifery services, and the development of hospital-based midwifery-led units is allowing more women to access midwifery-led care, which was a key theme running through the submissions received during the formation of the maternity strategy. We now have significantly enhanced safety and quality frameworks in place, with directors of midwifery, patient safety statements, serious incident management forums and quality and safety managers all working to ensure that services are delivered in a more standardised and safe manner. Another very significant service development, as recommended in the national maternity strategy, is the increase in access to routine anomaly scanning from seven hospitals and units in 2016 to 15 hospitals and units now. It is further envisaged that all 19 hospitals and units will offer 100% access to anomaly scanning by the end of this year.

We have improved clinical governance structures in place, with the national women and infants health programme established within the HSE and the ongoing implementation of maternity networks. As was outlined by the Minister, Deputy Harris, earlier, development funding has also been utilised to increase staff numbers working in the maternity services, which includes additional midwives, consultants, theatre staff, ultrasonographers and quality and safety managers. When considered in conjunction with our declining rate of births, these staff increases provide us with an improved staff to birth ratio. We are, therefore, better placed than we have ever been to ensure that all maternity hospitals, large and small, can provide quality services in the safest manner possible.

From a capital perspective, the national maternity strategy also sets out the Government's policy to co-locate the four remaining stand-alone maternity hospitals with acute adult hospitals, which will help to provide optimal clinical outcomes for women and their babies. Significant funding for those major projects is set out in the national development plan. As Members will be aware, the relocation of the National Maternity Hospital to the St. Vincent's hospital campus at Elm Park will be the first of the relocation projects to be progressed. To that end, officials in the Department of Health are engaging with both the National Maternity Hospital and the St. Vincent's Healthcare Group to develop a legal framework to protect the State's significant investment in the new hospital. In addition, work on the enabling and decant works is under way at St. Vincent's University Hospital which will allow for the construction of the National Maternity Hospital on St. Vincent's campus.

The national maternity strategy proposes a new model of integrated care that provides three care pathways - supported, assisted and specialised - which aims to ensure that every woman will be able to access the right level of care, from the right professional, at the right time and in the right place, based on her individual needs. As was set out in some detail by my colleague, the Minister, Deputy Harris, earlier, considerable progress has been made to implement that model of care. That, in turn, is helping to fulfil the strategy's vision of enabling women to have a wider choice of pregnancy and birthing experiences.

I would, therefore, like to reassure the House again that this Government remains committed to the progressive development of maternity services in this country through the implementation of the national maternity strategy. As such, this Government will continue to support the national women and infants health programme in progressing the strategy's implementation. This Government support will enable the underlying vision and recommendations of the strategy to be fulfilled, including that services should be woman-centred and provide integrated team-based care and that women should have increased choice at a very special, individual and private time for them and their families, while also crucially ensuring that the services they receive are safe.

The national maternity strategy represents a truly holistic and national approach to the design and delivery of maternity care in this country, which will fundamentally change how maternity care is delivered and will do so for the better. With the publication of the strategy and the establishment of the national women and infants health programme we have the policies, the plan and the leadership in place to deliver the safe, quality and compassionate service that mothers and babies in Ireland expect and deserve.

I thank the Minister of State for her personal compassion. I listened to the Minister, Deputy Harris, earlier and, to be honest, I was disappointed with his tone. He was incredibly defensive and used his time to attack the Fianna Fáil Party for using its Private Members' time to highlight what must be done to support women in this country. The Minister of State, Deputy Catherine Byrne, said that even one negative experience in our maternity services is one too many and that it is important to recognise how difficult these events can be for the women and families concerned. I support her statement. Her personal compassion is evident, even if her party's is not.

We are at our most vulnerable when we enter and exit this world, and the women who give birth are at their most vulnerable. It is very important that we put everything we can in place. The current national maternity infrastructure is putting women’s lives and the lives of their babies at risk due to lack of funding and a chronic shortage of midwives. The fact that a mere 3% of the HSE's budget goes on maternity services is a scandal, considering this country's tragic history of maternal deaths. It is important to name those women: Tania McCabe, Evelyn Flanagan, Jennifer Crean, Bimbo Onanuga, Dhara Kivlehan, Nora Hyland, whose wedding I danced at a few years before her death, Savita Halappanavar, Sally Rowlette and Malak Thawley.

Other Members have spoken about the women who called "Liveline". I understand that more than 1,000 calls were received. The testimonies were powerful. We must listen to what women are saying. Fair play to "Liveline" for giving those women the opportunity to add their voices to the debate. That is what we are doing on this side of the House. There were powerful accounts from women who were not listened to, who suffered dreadful pain, many of them for years after giving birth, and who were sent home traumatised by our maternity services. The calls came from women all over the country who had used all of our maternity hospitals.

There is no doubt that our infrastructure is letting women and babies down when they are at their most vulnerable. This infrastructure requires serious review and investment if we are to stop failing mothers and their newborns. What is needed is the new maternity hospital, the ongoing implementation of the 77 recommendations of the national maternity strategy, an audit of the ratio of midwives to women in labour, a plan for the provision of community midwifery services and the provision of alongside birthing units for midwife led care of low risk women in all our maternity hospitals. I note a letter to The Irish Times from the Midwives Association of Ireland last April which referred to the core problem being how and whether women get to make their decisions, supported by the midwives, because there are simply too few midwives.

I could outline the issues in all the maternity hospitals but I do not have the time. Conditions are dire in our maternity hospitals, particularly in Dublin. The Minister, Deputy Harris, has told us there is zero funding allocated in 2019 to even begin moving the Coombe. In 2017 the cost of compensation for errors and mistakes in our maternity units alone was 50% greater than the total funding made available for increasing health service provision in the State. That gives a strong message. When will the Government listen to women and provide them with the services they need and deserve?

I welcome the breaking news that tomorrow's strike in the hospitals has been called off. That will be a great relief for many people who will be seeking treatment tomorrow.

I also thank all the Members who contributed, the Minister of State for her contribution and the mothers and medical professionals who helped with drafting the motion. Deputy Lisa Chambers made the important points that the care must be woman-centred, which it is not at present, and that women must be in control. In many cases they are not. Deputy Rabbitte talked about the ongoing concerns in Portiuncla and referred to a heartbreaking case. She and I have met the couple concerned and I hope the Minister will meet them. Deputies Eugene Murphy, Catherine Martin, Butler, Ó Cuív and Kelly spoke about the lack of implementation. Good intentions, warm words and shiny brochures and launches are great, and we see them continuously, but it is about implementation.

I acknowledge the constructive input from Deputy O'Reilly and her party. Deputy Brady raised the issue of newborn screening. It involves our constituent, Mr. Martin, and I should let Deputy Brady know that I have passed the content from Mr. Martin to some senior consultants who are examining it. I acknowledge Deputy Buckley's incredibly important point about the need for mental health support services throughout the antenatal and postnatal process for mothers and, in some cases, for fathers. I also acknowledge Deputy Shortall's comments on the ongoing governance questions with regard to the national maternity hospital and the fact that we still have not seen it. Nothing has happened. There is a car park, but women cannot give birth in car parks. They give birth in hospitals or other appropriate care settings.

I was very disappointed with the response from the Minister, Deputy Harris. The motion is not politically pointed and does not overtly say that the Government is failing in all these matters. I expressly intended it to be a constructive debate. The Minister, Deputy Harris, spent the first few minutes of his contribution not talking about mothers and babies but about Fianna Fáil. He attacked Fianna Fáil. Fine Gael has been in government for nearly a decade. There comes a point when Fine Gael must take responsibility for things that are happening in this country and not try to defend itself by saying that Fianna Fáil did or did not do something 15, 20 or 25 years ago, whenever it may be. The reality is that when Fine Gael came into power in 2011 the economy might have been in serious trouble but the healthcare system was strong. Access to medicines was high and waiting lists were low. This Government has spent billions of additional money, yet access has never been worse and medical professionals have said they have never previously felt the same level of burnout and stress. That is what Fine Gael has done to healthcare. It must own its failures in healthcare. If it owns and accepts those failures, which are many and profound across this country, perhaps things will begin to improve.

The Minister went on to suggest there were issues of trust with Fianna Fáil and raised the repeal issue. It is a matter of record that the then Simon Harris campaigned in 2011 by writing to every pro-life group in Wicklow saying the groups should vote for him because he was pro-life and he would be the Deputy who would guarantee the eighth amendment is never repealed. While I was voting for repeal over numerous years, Deputy Harris voted against it every time until the last time, when he was handed it by Deputy Enda Kenny and the Labour Party. That is the record. With respect, he can keep his comments about trust to himself.

The Minister basically said in his speech that everything is awesome. The doctors, midwives and mothers do not think that. Are they all lying? Is everybody else lying that there is no problem in maternity care and that this Government has everything under control?

The Minister referenced Sláintecare, the aim of which is to provide equal care for all men, women and children. However, the new national maternity hospital, approved by this Government, will have a private wing. The new children's hospital will have a private internal entrance for the children of wealthy people and private suites. That is not Sláintecare or equality. It is literally physically building inequality into our country. It is a disgrace and it needs to be reversed.

This motion was not meant to be about political point-scoring but about maternity services and what is needed for mums, babies and for our healthcare professionals. What do they need? They need the new hospitals to be built. They need safe staffing levels and modern diagnostics, which we do not have. They also need many more supports for women in mental health and counselling services and in public health programmes for breast-feeding. There is an issue in this country around healthcare discrimination against women. There are now 556,000 men, women and children waiting to see a consultant but I found out recently from the Irish Patients Association that there are 80,000 more women waiting than men. How is this acceptable?

This debate was not meant to be political but was meant to be constructive. Let us work together to implement what we all agree is a good strategy and let us systematically remove the gender based discrimination across the health service in this country. Finally, let us applaud the healthcare professionals and acknowledge the incredible work they are doing in what is becoming an ever more difficult situation. They need our help.

Amendment put.

In accordance with Standing Order 70(2), the division is postponed until the weekly division time on Thursday, 20 June 2019.