Health Committee on April 8th, 2024

[Élisabeth Brière, Liberal, Sherbrooke, QC]

Okay.

Did you want to wrap up your remarks, or had you already finished?

[Dr. Tina Montreuil]

I have results regarding what I said earlier. We have already carried out the work. In Quebec, an ongoing pilot project funded by the Canadian Institutes of Health Research seeks to provide an online intervention to improve emotional regulation and shed light on many of the changes that occur during pregnancy.

We aren't just talking about biological and physiological changes, which are already part of prenatal care. We're also talking about the whole psychological component, which is often overlooked. We're working extensively with peer support workers in the province. The postpartum bible contains 300 to 400 pages on the baby and baby care, but only two or three pages on postpartum mental health.

I want to point out something. Right from the start of the postpartum period, we recommend, for example, following the protocol for checking car seats to ensure that babies are transported safely and correctly home. There's also a protocol for shaken baby syndrome. I agree with these routine practices. However, when it comes to child abuse, we know that the parent's mental health is the precursor. In that case, when checking the baby's seat and the risk of the mother or father potentially harming the baby, why aren't we also addressing the precursor, or how the parent is coping with the new situation of living with a baby? The transition to parenthood isn't the same for everyone. This must be taken into account.

At the start, most people are still wondering about the available resources, and how they can access them. Many resources are available to parents right now. However, we still need to work on integrating these resources into health care communities. I also believe that, even in this day and age, we can inform parents about the resources available, and still wonder why they aren't accessing them. The stigma aspect is a major issue.

As Ms. Hippman said, pregnancy is an opportunity to build relationships with the health care system, so that we can better prevent issues within families.

[Élisabeth Brière, Liberal, Sherbrooke, QC]

Thank you. You answered a number of my questions, which opens the door to other questions.

Could training be included in prenatal courses?

[Dr. Tina Montreuil]

I believe so. Absolutely.

We also have a pilot project in Quebec. This project is funded by the Fondation de la recherche pédiatrique, or pediatric research foundation—formerly the Fondation des étoiles—and by the CHU Sainte‑Justine. The project is the ECHO program, an online telementoring program.

We heard today about why people feel unable to carry out screening. We heard that treatment in general already includes a mental health component. However, we know that this isn't the case. Studies show this. The reason is that professionals, who are generally equipped to deal with a number of situations, don't feel equipped to really screen for mental health issues. Like other programs in Canada, this telementoring program helps to bring our health care professionals—midwives, doctors, nurses and social workers—up to speed with the tools needed.

When people are equipped, they feel better able to carry out screening. We know that investing a bit of money in training through this pilot project will enhance our health care system with the people already on the ground. We still need to hire more people for this, or to reorganize our resources. However, we can plan certain measures by establishing guidelines for doing so.

[Élisabeth Brière, Liberal, Sherbrooke, QC]

Do you think that interdisciplinary work is key?

[Dr. Tina Montreuil]

It's a key component. In 2022, we carried out an activity with the Alliance québécoise pour la santé mentale périnatale, or Quebec alliance for perinatal mental health. We recently had the chance to share our results at an event organized by the Daymark Foundation, which brought together Canadian policy‑makers.

We spoke with a number of target individuals who can affect mental health, particularly women's health in Quebec. We identified three major obstacles. One obstacle is the integration of resources. There are already resources, but their interconnectedness poses an issue. Efforts are duplicated and work is done in silos.

We must first acknowledge that perinatal mental health is a public health issue. We must then determine how to reorganize and integrate many of the players involved. We also saw this at the Daymark Foundation event. It was demonstrated that a number of key community players could be better integrated into the health care system to ease the burden of this transition. We must assess the existing resources and determine how to combine them to make this feasible and achievable.

[Élisabeth Brière, Liberal, Sherbrooke, QC]

Thank you, Ms. Montreuil.

[The Chair, Liberal, Sean Casey]

Thank you, Mrs. Brière and Ms. Montreuil.

I'll now give the floor to Ms. Bérubé for six minutes.

[Sylvie Bérubé, Bloc, Abitibi—Baie-James—Nunavik—Eeyou, QC]

Thank you, Mr. Chair.

I want to thank the witnesses for being here today, and for their valuable expertise.

Ms. Montreuil, you spoke earlier about marginalized women. What are the health outcomes for marginalized women before and after childbirth?

[Dr. Tina Montreuil]

We know, for example, that a number of issues affect marginalized women. I spoke about pre‑eclampsia or other types of inflammatory diagnoses that affect marginalized women in different proportions to the rest of the population. Sometimes, we look at these types of statistics and think that this proportion isn't very significant compared with other types of statistics.

However, we must also consider that these women are under‑represented. As researchers, we all know this. When we ask women to participate, we generally try hard to reach out to under‑represented people. This still poses a hurdle. The issue of trust in our motives still arises when we carry out these types of studies.

Unless we specifically focus on these people, many of our studies don't provide representative results. We can benefit from working with communities and community partners, because they have already built relationships. In our indigenous populations and in the populations of Black women with whom we often work, these women are already integrated into many of the community resources. To ensure more representative results, it would be much better to work more with these community organizations, which have already established a bond of trust.

I'm providing this common example because of time constraints. However, it's something to consider. I think that we should also support the work of the Canadian task force on preventive health care, while funding more research that specifically focuses on these women.

Implementation science projects are expensive. They involve not only a community of researchers, but also practitioners accustomed to often conducting research. We must work with people who have lived experience in the community and who aren't experts in the field. We need funds to carry out proper studies, not just observational studies, which are limited in terms of positioning.

[Sylvie Bérubé, Bloc, Abitibi—Baie-James—Nunavik—Eeyou, QC]

I have another question for you. I come from the constituency of Abitibi—Baie‑James—Nunavik—Eeyou. Our area is considered remote. We're well aware that many women experience post-partum, child loss, and so on. We know that the CHU Sainte‑Justine is there. However, the process in remote regions is complicated. As a result, these women often don't necessarily have the tools available to cope.

As a researcher, what's your perspective on monitoring in Quebec?

[Dr. Tina Montreuil]

First, when we work with the women who contact us through the alliance, we can see that much more remains to be done in terms of post-partum follow‑up care.

We recently recorded a podcast with a woman who said that post-partum follow‑up care for the mother doesn't exist. During the post-partum period, her child had 10 follow‑up visits with the pediatrician. Yet, at every meeting with the pediatrician, the mother was, as she put it, dying inside. She really wanted someone to ask her how she was doing, but the question never came up. She considered broaching the topic, then changed her mind. She thought that she would be deemed a bad mother for focusing on herself rather than on her child.

All this to say that the issue isn't straightforward. Having already worked in various areas, such as Gaspésie, I can see that we have plenty to do in terms of the first level of intervention. Research and clinical studies show that we must give people access to resources, while providing these resources with a type of seal of approval from the province.

For example, I'm involved in creating an initiative that will be implemented in Quebec in the coming months. Basically, when we provide a service, we give it a type of departmental seal of approval. At every prenatal visit, right from the start, we bring up the fact that services are available to women should they experience any difficulties during their pregnancy. We can then combine this, for example, with the ECHO telementoring model.

I haven't yet brought up other studies that we carried out and another initiative that we implemented to give people an additional tool. This tool involves Internet access, but also a follow‑up with a mentor such as a nurse or a social worker for people who found the first level of intervention too basic and insufficient and who needed something more.

If necessary, we can then refer some people to psychiatric services. By providing the services at the first two levels of intervention, we can probably solve many problems. We have seen this in school settings. I work a great deal on level 3 interventions. With level 1 and 2 interventions, we can address about 70% of cases that would otherwise require a psychiatric consultation. The leaves us with 30% of people who will actually need to see a psychiatrist. This will automatically lighten the workload of these specialists.

When I talked about reorganization, this was also a factor to some extent. We must look closely at all the cases currently referred to level 3 to see whether these people could receive care at levels 1 and 2. This would lighten the load on the health care system, while meeting the needs of the more isolated communities that you referred to.

[The Chair, Liberal, Sean Casey]

You still have 20 seconds, if you wish, Ms. Bérubé.

[Sylvie Bérubé, Bloc, Abitibi—Baie-James—Nunavik—Eeyou, QC]

Ms. Hippman, can you describe how pregnancy loss or infertility affects a person's mental health?

[The Chair, Liberal, Sean Casey]

Please keep your answer brief.

[Dr. Catriona Hippman]

All right.

Well, it can be very difficult. I don't know the exact rates of depression, but they're high. Infertility can be incredibly stressful and can lead to anxiety and depression. In loss, it can be difficult to tease apart postpartum grief reaction versus postpartum depression, but it's important not to dismiss postpartum depression, assume that it is grief and not have good support for people in that context too.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Hippman.

Thank you, Madame Bérubé.

Next is Ms. Idlout, please, for six minutes.

[Lori Idlout, NDP, Nunavut, NU]

Qujannamiik, Iksivautaq. Thank you, Chair.

It's a pleasure to be here. Thank you to all the witnesses for all their expert testimony. I think I will be asking Catriona Hippman most of my questions. The reason I kind of struggle to ask general questions is that all the witnesses come from very different institutions and different parts of Canada.

I'm interested in hearing about the standardized screening that you recommend, but before I get to that kind of questioning, I want to ask specifically about indigenous women. How long has it been known, would you say, that indigenous women are more vulnerable to mental health issues?

[Dr. Catriona Hippman]

I feel like we need to continue to expand our attention in that area. I do see that there is more research happening and more attention being paid to support mental health for the indigenous community, but it's still early days. There's such a problem with the lack of trust, as has been mentioned and as I'm sure you're all aware, in terms of someone actually being able to feel comfortable self-identifying as indigenous.

There's a program now at BC Women's Hospital. We have a system in place to connect indigenous patients with an indigenous peer support worker and an elder, but they need to feel comfortable identifying as indigenous. Given what we know about racism in the health care system and all of the discrimination and the negative, harmful impacts that can have, it's understandable if indigenous people don't feel comfortable sharing that they are indigenous or coming to the health care system at all.

It's a big issue, but we are working to find ways to build that trust with the community and trying to find a way to meet their mental health care needs in the perinatal period.

[Lori Idlout, NDP, Nunavut, NU]

At the risk of asking you to generalize, which I'm not, what are some of the issues? What are some of the realities that make indigenous women more vulnerable to mental health issues?

[Dr. Catriona Hippman]

One thing, off the top of my mind, is the histories of intergenerational and personal trauma. Pregnancy is a time when trauma can really come to the surface in ways that people don't expect. You grapple with identity shifts and it connects to your ancestors and generations going forward. It's a really sensitive time, and I think it's not adequately appreciated or supported.

It's wonderful to hear from Dr. Vigod about the stream of support for trauma-informed care in their programs. Generally speaking, I don't think that's a strong element of our health care system. There needs to be support for people going through pregnancy to pay attention to and provide care for their trauma, which they may need to process if it is triggered.

[Lori Idlout, NDP, Nunavut, NU]

In terms of moving toward making recommendations about standardizing screening, how would you ensure that it incorporates the need to reflect and understand what indigenous women may have gone through so that we include those struggles in some form of standardized screening?

[Dr. Catriona Hippman]

It's such an important issue to think about. There's a history of removing children from indigenous families, which is just so tragic. That has been seen as part of the perinatal health care system as well and has manifested in a practice known as birth alerts for indigenous women. After the birth, they would be seen by a child and family development worker and there was a higher risk that their child would be removed. That practice has ended, but relatively recently, I think, in 2019. There's still that history and a very valid fear that if an indigenous person comes to the system with a pregnancy, their child is going to be taken away from them. To add to that, if they're asked if they are experiencing depression or some other mental illness, that's more ammunition for taking away their child.

I can understand that being a really sensitive problem. We need to have more tailored screening approaches for indigenous communities so that they do not feel threatened, and embed that within a system from which they can receive culturally sensitive and trauma-informed support.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Hippman.

Thank you, Ms. Idlout.

Next we have Mrs. Roberts, please, for five minutes.

[Anna Roberts, Conservative, King—Vaughan, ON]

Thank you very much, Mr. Chair.

Thank you to the witnesses.

I'm going to go back to a question that my colleague Karen brought up, and that's the family doctors and the lack of them.

Last Wednesday, there was an announcement made in Ontario—I'm from Ontario, by the way—that the Ontario government is going to provide $9 million to York University to build a medical school right next door to Cortellucci Vaughan Hospital, specifically for family physicians. I see that you heard about it. It is quite interesting. If I look at the stats in Ontario, I see that 2.3 million people do not have family doctors, and in 2026, four million people will be without family doctors. That's one in four people—and that's just in Ontario. Here's the kicker, though. The school will not be built and finished for occupancy until 2028, and then I think it's another four years....

We're so far behind with family doctors. I know that we Conservatives have a really good plan with our blue seal plan to bring doctors in. In listening to you, I know it's important that we identify these issues so that we can protect women.

In 2018, there were 8.3 maternal deaths per 100,000. It looks like it has doubled in the past 10 years. It is something that is really important, if we're going to stand up for women.

I don't know, but I guess I'm just not normal, because I lost five kids. I think what helped me was my faith and my family and the support system I had around me, which helped me get through it. When I did get pregnant, they made me stay in bed. I think that was worse than anything else, because I'm not the type of person who likes to sit still.

Do you think that those support systems, because of COVID—I know you mentioned COVID—just fell by the wayside?

I'll leave it open to anyone who would like to speak to that.