Health Committee on April 8th, 2024

[The Chair, Liberal, Sean Casey]

I call this meeting to order.

Welcome to meeting number 108 of the House of Commons Standing Committee on Health.

This is just a quick safety reminder not to put earpieces next to the microphone, because it causes feedback and potential injury. In accordance with our routine motion, I'm informing the committee that all remote participants have completed the required connection tests in advance of the meeting.

Pursuant to Standing Order 108(2) and the motion adopted on May 16, 2022, the committee is resuming its study of women's health.

I'd like to welcome our panel of witnesses. We have with us today Dr. Catriona Hippman, postdoctoral research fellow, B.C. reproductive mental health program, B.C. Women's Hospital and Health Centre. By video conference, we have Dr. Ryan Van Lieshout, associate professor, department of psychiatry and behavioural neurosciences, McMaster University. Also by video conference, we have Dr. Simone Vigod, professor at the University of Toronto and head of the department of psychiatry at Women’s College Hospital. From the Québec Alliance for Perinatal Mental Health, we have Dr. Tina Montreuil, associate professor and scientist for the Montreal antenatal well-being study.

Welcome to all of our witnesses. We're going to begin with opening statements of five minutes or less.

Dr. Hippman, we'll start with you. The floor is yours.

[Dr. Catriona Hippman, Postdoctoral Research Fellow, BC Reproductive Mental Health Program, BC Women's Hospital and Health Centre, As an Individual]

Thank you very much, and good afternoon.

Today, we are calling for an urgent revision of the Canadian task force guideline on perinatal depression screening. This guideline undermines decades of work by experts in B.C. and across Canada to promote universal standardized screening, and places the burden of advocating for their mental health on Canadian women at an incredibly vulnerable time in their lives. We can, and should, do better.

My name is Catriona Hippman, and I'm a post-doctoral research fellow with the B.C. reproductive mental health program, the University of British Columbia and the University of Calgary. I'm a Canadian Institutes of Health Research fellow and a Michael Smith Health Research BC fellow.

Perinatal depression is an important public health issue. It affects 10% to 15% of women, with even higher rates among marginalized groups, affecting almost half of immigrant and indigenous women. In light of this, it's unsurprising that suicide is a leading cause of maternal deaths in Canada.

Early identification is key to improved outcomes. When caught early through universal standardized screening, perinatal depression can be successfully treated, and negative downstream consequences for the child and the family can be prevented. Not only can we prevent disastrous outcomes for families with early identification, but we can also save costs for the health care system. A 2021 report by the Canadian Perinatal Mental Health Collaborative demonstrated that costs of $150,000 for each mother-baby dyad affected by perinatal depression and anxiety could be reduced to $5,000 per family with universal standardized screening.

Given this context, it is shocking that the Canadian Task Force on Preventive Health Care currently recommends against universal standardized screening for perinatal depression. This recommendation contradicts screening recommendations within Canada as well as worldwide, including in the U.S., the U.K. and Australia.

At the B.C. reproductive mental health program, we set the standard of care for British Columbia through clinical practice guidelines, resources and interdisciplinary education. We're a national leader in perinatal mental health care, providing over 5,000 direct patient care visits per year and indirect care for countless patients through a rapid consultation service to B.C. primary care providers. As determined by the reproductive mental health program, the standard of care in B.C. includes universal standardized screening for perinatal depression.

In contrast, the Canadian task force recommends that perinatal depression screening occur “as part of usual care”. This means that only patients flagged by their primary care provider will receive additional attention. This is simply not enough. A study in Alberta in 2021 documented that in “usual care”, approximately two-thirds of cases of perinatal depression were missed. This study estimated that 2,000 cases of postpartum depression could have been detected with universal standardized screening.

“Usual care” places the burden of advocating for their mental health on Canadian women. We know that our health care system is strained, and the reality is that under “usual care” conditions, it's the patients who need to bring perinatal depression to the attention of health care providers. What's more, “usual care” is inequitable care. Research has demonstrated that when perinatal depression screening is left to the discretion of the health care provider, racialized patients are less likely to get screened. White women are more likely to have their concerns taken seriously, and women with socio-economic privilege have the greatest capacity to advocate for their own care. This perpetuates health inequalities and further marginalizes Canada's most vulnerable.

You might think that we just don't like the conclusions that the task force reached, but it's more than that. Their conclusions are not justified. The systematic review on which the guideline was based identified a single randomized controlled trial, or RCT, which found that participants who had universal standardized screening had improved maternal mental health outcomes at six months postpartum. Further, the patient values and preferences studies conducted by the Canadian task force highlighted that participants felt the potential benefits of screening outweighed the potential risks. Participants characterized potential harms of screening as trivial. Our perspective aligns with that of the patients in this study, who felt that “risks of overdiagnosis or its resulting treatment were not considered critical in comparison with failure to diagnose depression”.

In summary, the task force prioritized concerns about speculative harms over documented benefits, the perspectives of patients and the opinions of experts.

We need to take the burden off Canadian women. Universal standardized screening promotes equitable access for all Canadians to have a mentally healthy pregnancy and postpartum. We need a Canadian task force guideline that prioritizes preventive health care.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you very much, Dr. Hippman.

Next, we're going to go to Dr. Montreuil with the Québec Alliance for Perinatal Mental Health.

Welcome to the committee. You have the floor for the next five minutes.

[Dr. Tina Montreuil, Associate Professor and Scientist, Montreal Antenatal Well-Being Study, Québec Alliance for Perinatal Mental Health]

Thank you.

I am an associate professor at McGill University, in the department of education and counselling psychology, as well as an associate member of the departments of pediatrics and psychiatry. I am also a scientist at the Research Institute of the McGill University Health Centre. As such, I bring together the perinatal mental health expertise and early childhood development. This is what I'm going to advocate for today.

I will add on to what my colleague mentioned.

The perinatal period is defined as the gestational period of pregnancy until 12 months postpartum. We know that perinatal mental health disorders, such as depression and anxiety, are among the most common complications of childbirth, affecting as much as 20% of pregnant and postpartum individuals. The rates of postpartum depression have doubled since the COVID-19 pandemic. This is from a source provided by Inspiring Healthy Futures, with the contribution of Health Canada and the Public Health Agency of Canada. The source estimates that the incidence of mental health issues among both women and men have increased by more than 10%.

These statistics are reported to affect an even greater number of women in marginalized and under-represented populations, such as IBPOC women, who are disproportionately affected by mental health issues and are most often missed in these reported studies. We're not specifically targeting these populations and, as such, it questions the generalizability of the findings that we often report.

More than 350,000 individuals become pregnant in Canada every year, which suggests that up to 105,000 Canadians may experience perinatal anxiety and mood disorders, making them the most common pregnancy complication. Pregnancy complications don't just have implications during pregnancy, such as gestational hypertension, pre-eclampsia or gestational diabetes, which have received recognition for their predictive roles in the incidence of more chronic disease later on in a woman's life. This is not the case, however, for mental health during that same critical period of women's health.

It was mentioned that maternal suicide is a leading cause of maternal death in high-income countries. Maternal depression and anxiety are associated with an increased risk of preterm birth, low birth weight and child social, emotional and behavioural difficulties. This is where my child expertise comes in. It's also known to basically continue to have a lifelong effect into adolescence and be associated with mental health issues in teenagers into adulthood.

Some causal analyses have been conducted in the United States, the United Kingdom and Australia. These are countries that are very comparable to the one that we are living in, Canada. They highlight the significant economic impact of untreated perinatal mood and anxiety disorders in Canada. Thus, many experts working in the area, such as us here today, do question the lack of early detection and appropriate treatment of maternal depression and anxiety, as well as its consideration as a public health priority.

Unlike other gestational conditions affecting the pregnant person, mental health issues remain the most underdiagnosed. To just give a little representation or equivalent, according to Diabetes Canada, gestational diabetes affects one in 10 women—we said that mental health issues affect about 20% of women. One in every 632 births would result in a baby with potential complications such as Down's syndrome. This, again, is according to Health Canada data. This data alone has sufficed over the years to understand the need to conduct and maintain systematic nuchal translucency and gestational diabetes screenings as part of routine prenatal care. Despite what we know of the incidence of mental health issues and the fact that they affect both the woman's health and the child in terms of intergenerational transmission, we do not have the same type of screening when it comes to mental health issues during pregnancy. It's not part of our prenatal care, unlike some of the countries that I mentioned before, which are developed countries like ours.

That being said, given the high prevalence and adverse consequences of perinatal mood and anxiety disorders, several countries have now recommended—as has been mentioned before and will be mentioned again—the need for routine screening for prenatal anxiety, depression and other mental health issues during the course of pregnancy. The failure to identify these risk factors of adverse perinatal mental health outcomes can have negative consequences for the mother, as I mentioned, but also for the child.

Using an existent evidence-based model stemming from the London School of Economics, we've been able to conduct this same type of economic impact calculator with the Montreal antenatal well-being study that I represent. The economic impact tool was necessary to determine the economic cost of perinatal health mood disorders and also enable us to make these estimations throughout every province. We are now upscaling this tool to include cost-effectiveness of interventions and referral interventions in the Canadian context.

The first phase of our economic impact calculator has produced an estimate that a lack of routine screening in Canada would lead to a cost of about $6.7 billion per year in Canada. The cost of perinatal mental health illnesses in Canada is associated with about $46,000 per birth for deliveries, and about 70% of these are accountable to the child. The child would basically go on to develop such adverse effects and outcomes as poor cognitive functioning, which is also impacting their future development.

The evidence speaks for itself. The benefit to the mother or pregnant person can be achieved via preventative care during the prenatal phase. Not only can this present as a benefit to the woman during pregnancy; it could also play a critical role in early detection and prevention of other postpartum diseases, as I've mentioned, such as breast cancer, cervical cancer, cardiovascular disease, diabetes and osteoporosis.

Using a precision health framework—

[The Chair, Liberal, Sean Casey]

Dr. Montreuil, can I get you to wrap it up? You'll have lots of time to expand on this during questions.

[Dr. Tina Montreuil]

Absolutely.

We've already been able to address that it's a benefit to the woman during the pregnancy but also postpartum. As a benefit to the child, targeting perinatal mental health issues is optimal for their development, and it contributes to society from a human capital standpoint.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you very much, Dr. Montreuil.

Colleagues, we are having some technical difficulties with the connection to our online participants. We will suspend to get those resolved before we invite them to present their statements.

The meeting is suspended, hopefully for just a short few minutes.

[The Chair, Liberal, Sean Casey]

I call the meeting back to order.

As you can tell by the length of the suspension, we have some highly trained professionals here in the IT support team for committees. It appears we're back in business. I hope I didn't jinx it.

Dr. Van Lieshout, welcome to the committee. You have the floor for the next five minutes.

Oh, no. We can't hear you, Doctor.

[Dr. Ryan Van Lieshout, Associate Professor, Department of Psychiatry and Behavioural Neurosciences, McMaster University, As an Individual]

Is this better? Can you hear me now?

[The Clerk of the Committee, Mr. Patrick Williams]

We're good to go. Thank you very much.

[The Chair, Liberal, Sean Casey]

Thank you very much. Thanks for your patience.

Dr. Van Lieshout, you have the floor.

[Dr. Ryan Van Lieshout]

Thank you again.

Good afternoon. I'm Dr. Ryan Van Lieshout, Canada research chair in perinatal mental health and the Albert Einstein/Irving Zucker chair in neuroscience at McMaster University.

I'm a psychiatrist and a clinician scientist who works with individuals struggling with their mental health during pregnancy and the first postpartum year, and whose research focuses on developing scalable psychotherapies for those with perinatal mental health problems. We also aim to optimize the delivery of these treatments to maximize their impact on offspring brain development. The primary goal of my work is to disrupt the intergenerational transmission of psychiatric problems from parents to their children.

My clinical expertise led to my invitation to co-author Canada's national practice guidelines for the treatment of perinatal psychiatric problems and Public Health Ontario's perinatal mental health tool kit. Throughout my career, I have seen the devastating effects that mental health problems occurring during pregnancy and the postpartum period have on children and families, and I have committed my work to reducing their impact.

As the other experts suggested today, perinatal mental health problems affect up to one in five women, but the disproportionate effects of the COVID-19 pandemic on mothers led these rates to increase to one in three. As previously mentioned, each case of postpartum depression alone is associated with costs of up to $150,000 over the lifespan, two-thirds of which is attributable to offspring.

Even though effective treatments can help both mothers and their children, as few as one in 10 pregnant and postpartum persons are able to access evidence-based care in this country. There are many barriers to the receipt of timely perinatal mental health care in Canada. One of the most significant of these is the current absence of coordinated care pathways that identify sufferers and match the right person to the right treatment at the right time. Second, since most individuals with perinatal mental health problems will respond to psychotherapy, talking therapies and/or medications, another significant challenge is the relatively limited knowledge possessed by frontline physicians about the safety of these medications during pregnancy and lactation. Finally, the profound lack of access to evidence-based psychotherapies, driven primarily by a lack of health care providers trained to provide them, prevents us from meeting our goal of becoming the best country in the world to raise a child.

However, there are many reasons for hope. A group of Canadian clinician scientists, of which Dr. Vigod and I are members, is working with the Canadian Network for Mood and Anxiety Treatments to prepare national practice guidelines for perinatal mental health problems, which can be used to help educate frontline providers and guide the creation and application of Canadian-specific care pathways. These structured care pathways—integrated systems that involve the detection of mental health problems, direct patients to the right resources at the right time, and provide treatment and follow-up—need to be tailored for the Canadian context and implemented.

Once these pathways are created, they will enable us to use evidence-based psychotherapies, developed and tested right here in Canada, to optimize treatment. However, there exists a substantial shortage of trained mental health care professionals required to deliver these interventions. To address this, our group has developed and tested several effective, scalable psychotherapeutic interventions that can be delivered by a variety of individuals, including public health nurses, with no previous psychiatric training or even individuals who have recovered from psychiatric problems themselves, also known as recovered peers.

These treatments can serve as both initial and more intensive steps in care models. For example, our one-day cognitive behavioural therapy-based workshop for postpartum depression can effectively treat up to 30 individuals at a time and be delivered online or in person by public health nurses or recovered peers. Our nine-week group cognitive behavioural therapy intervention has also proven effective, and its delivery has already been successfully task-shifted to recovered peers and public health nurses with limited to no previous psychiatric training. These have already been scaled up and are in use in Canada, Europe and the United States.

As Dr. Montreuil pointed out, we know that when mothers get these treatments, they help not only them but their offspring as well. Perinatal mental disorders are among the most common adverse childhood experiences. The research by our group and others has shown that treating mothers with postpartum depression leads to clinically meaningful improvements in mother-infant relationships, infant brain development and emotion regulatory capacity, and even the mental health of the older children in the home. This is in keeping with research from around the world that suggests that for every dollar invested in early childhood interventions, society reaps a $7 return.

Perinatal mental health problems in Canada can be prevented, detected and treated, and we already have the know-how to support mothers and disrupt the intergenerational transmission of mental disorders in families. The federal government can help by working together with experts to create Canadian-specific care pathways, scale the perinatal mental health workforce to meet the needs of mothers, and work together with the provinces to implement these systems. Such developments will enable our Canadian-made discoveries to improve the health and lives of all Canadians.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Van Lieshout.

Finally, we have Dr. Simone Vigod from the University of Toronto and the Women's College Hospital.

Welcome to the committee. You have the floor.

[Dr. Simone Vigod, Professor, University of Toronto, and Head, Department of Psychiatry, Women’s College Hospital, As an Individual]

Thank you to the chair and the committee for inviting me to present today on the topic of the mental health of women.

By way of introduction, as you've heard, I am a psychiatrist. I'm the head of the department of psychiatry at Women's College Hospital in Toronto, where I also hold a research chair in women's mental health. I am also a professor of psychiatry in the Temerty Faculty of Medicine at the University of Toronto. For the past 15 years, my clinical practice and research have focused on women's mental health.

What I wanted to talk to you about today is how and why I believe that the mental health of women is a major public health issue for you to consider.

From menarche—the time when people get their periods—to menopause, women are two to three times more likely to develop common mental health problems such as depression and anxiety than their male counterparts. Mental health problems in women, of course, affect their well-being and productivity. Because women are often caregivers of all others in their sphere, when they are unwell, this can also negatively impact their children and families.

When I talk to my students, partners and the community about this, I usually say there are issues of mental health that are unique to women. You've heard about some of those today, including pregnancy, of course. Then, there are issues that disproportionately or differently affect women. Biologically, there are unique considerations. For example, mood problems that fluctuate with the menstrual cycle might require different treatments or different medication regimens. We've heard quite a bit about pregnancy already today. I would add that treatment decisions in pregnancy, and when someone's breastfeeding, require us to think about the potential for impact on a baby. Also, even the way women absorb and metabolize medications, they do this more slowly than men, so a dose of a medication, for example, that was established for an often larger or heavier man in the clinical trials might lead to toxic side effects.

Of the issues that disproportionately affect women's mental health, one of the biggest is physical, emotional and sexual abuse and assault, which is much more common in girls and women. You probably know that trauma changes the brain. It increases the risk for depression, anxiety and post-traumatic stress disorder substantially. In fact, we now know that more than 50% of women with mental illness report having experienced prior trauma.

Women are also at elevated risk of poverty, isolation after immigration, and stress due to caregiving, among other factors, which can not only increase their risk for illness, but also increase the barriers to their receiving care.

I thought I would tell you a bit about how our department of psychiatry at the University of Toronto at Women's College Hospital has addressed this. Dr. Van Lieshout works in a very similar program at McMaster University. We are one of the University of Toronto's main academic health sciences centres, and we've really taken these considerations to heart.

Our department comprises clinical programming as follows. First, a reproductive life stages program for women who experience mental illness related to the menstrual cycle around the time of pregnancy is very important, as you've heard today, as well as around the time of perimenopause. Second, we have programs that cater to women from at-risk populations, including immigrants, refugees, indigenous women and women experiencing addiction. Third, we have a trauma therapy program for women who've experienced emotional, physical and sexual trauma and now are experiencing complications of mental illness.

Within these programs, because we're a university hospital centre, we're dedicated to expanding knowledge beyond our walls, via research and education. We study causes of illness, such as in our Canada-wide study of postpartum depression genetics. We identify novel treatments, as well as how best to use existing ones. For example, we're using non-invasive neural stimulation to treat depression in pregnancy for women who are worried about using anti-depressant medications. Also, we just received funding from the Canadian Institutes of Health Research to look at ADHD medications in pregnancy, because this is dramatically increasing in use among women. We also, as you've heard today, develop and test innovative models of care to improve access in the pregnancy period, but also to expand access to trauma-focused therapies.

Finally, we train clinical providers across all disciplines—not just psychiatrists, but also social workers, psychologists, midwives and people in multiple other areas of medicine that are related to ours, such as endocrinologists and gynecologists—so that those who are new providers and those who have been in practice for many years can help to better treat the 50% of their patients who are women.

However, as you've heard from my colleagues today, while we're making excellent progress, the goal of having all women with mental illness in Canada receive timely, effective mental health care has not quite yet been achieved.

I believe some great impact on a national level would be to invest in the following concrete, actionable priorities in women's mental health. First, I would recommend a mental health awareness campaign about women's mental health, to empower women to know what they can and should expect about their mental health and from their treatment. The second is to really champion the education and training opportunities in women's mental health, such as those that we, Dr. Van Lieshout's team and others have developed across the country. The third is to increase the targeted research opportunities to both improve the experience of care for women with mental illness today and to develop prevention and cures for the women of the future.

Given the large number of Canadian women affected by mental illness, even small gains in meeting the mental health needs of women across their lifespan have the potential to lead to a large positive impact on the health of all people in our communities.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Vigod.

We're going to begin with rounds of questions, starting with the Conservatives.

Mrs. Vecchio, go ahead, please, for six minutes.

[Karen Vecchio, Conservative, Elgin—Middlesex—London, ON]

Thank you to all of the different witnesses today for bringing their professional opinions and work to this.

I'm going to start off very simply. We know that one in five Canadians doesn't have a family physician. I believe this would probably be one of the biggest challenges. I see that most of you are in the academic field, but perhaps you can share with me what you know about this. If you don't have a family doctor when you're pregnant, what do you do? It's important to have these task force guidelines, but if there's not somebody monitoring them all the time, what do we do in that situation?

I want to pass it over to Dr. Hippman.

Could you share with me some of your thoughts on that?

[Dr. Catriona Hippman]

Yes, that is a really important issue.

In British Columbia, you can also directly access midwifery care. I think the perinatal period represents a little bit of a unique moment in a woman's life where there's a greater chance that she would be able to connect with a family doctor. I've heard anecdotal stories of people being able to get a family doctor when they are pregnant. I think that's somewhat optimistic for being able to have that continuous care.

I'd also suggest that it could be beneficial to consider more of the self-screening and self-care options that exist. For example, I know of research in Alberta where a study has basically instituted a program online that empowers women to do screening for themselves. Then it can also connect them with online self-help, like self-care or self-directed cognitive behavioural therapy and that kind of thing. We can kind of let them do it.

[Karen Vecchio, Conservative, Elgin—Middlesex—London, ON]

Wonderful, I really appreciate that.

Hearing the testimony today, when we talk about perinatal care and postpartum depression, I've always thought only about hormones, but many of you have talked about the environment as well. We know that trauma adds to the environment. When we're looking at the hormones.... Actually, I'm going to pass this over to Dr. Van Lieshout, because he talked about the medications.

As a mom of five, that's very important to me. Going through depression, going through anything...watching what you're eating and watching what you're drinking so you ensure your child is safe.

Can you share with me what they're currently using when it comes to helping maybe with the hormonal....or what things are safe?

[Dr. Ryan Van Lieshout]

That's a great question. Thank you for asking.

As I mentioned, under Dr. Vigod's leadership, we're currently preparing the latest version of the clinical practice guidelines for the treatment of a range of mental health problems during pregnancy and the postpartum period. When we reviewed the literature carefully again, it appears that there's a relative lack of knowledge among a lot of professionals about the relative risks and benefits.

People often hear horror stories about things like this or read things online, but the vast majority of the medicines used to treat depression and anxiety have a relatively good safety record. It's not that every person who has a mental health problem should be prescribed a medication, but it's really important that those who are already taking it, as well as their health care providers, are aware of the relative benefits and risks of these treatments. It's important that people who are thinking about taking them don't just automatically turn them down because of things they're uncertain about or their health care providers are uncertain about.

We're so happy to have this opportunity to update these guidelines and disseminate this information to all the frontline care providers we work with, who are doing such excellent work with the women, mothers, pregnant persons and birthing parents.

[Karen Vecchio, Conservative, Elgin—Middlesex—London, ON]

Thanks so much.

I heard many of you also speak about peer-to-peer...and a variety of different things we can do. That counselling piece, I think, is so important. If you're looking across Canada, for someone to get into counselling if they have had a child, what kind of time frame is there for waiting to have either peer-to-peer counselling or a counselling session with a group or one-on-one? Could you tell me what the timelines are for someone to access a physician on this issue?

[Dr. Catriona Hippman]

In British Columbia, for example, there's the Pacific Post Partum Support Society, which provides support by phone or by text message. A person who is experiencing postpartum depression can connect with a peer who is on the other end of the line. The hours are not 24-7, but it's very accessible.

In terms of more formal counselling, that would depend on how much money you have to access it privately. If you can afford it, then you can get it almost right away. If you need to go through the public system, that can take six or eight months. It depends.

[Dr. Tina Montreuil]

I think the lack of Canadian guidelines when it comes to screening and providing care has led—across Quebec, for example—to very different types of programs being delivered based on the institution. For example, at Sainte-Justine hospital, where I happen to work, they have a stepped care approach. We have a chief OBGYN over there who is very much attuned to the reality that we've depicted today. Therefore, for all women being seen at that institution, there is a screening and referral process in place.

You were also talking about self-care. There will be a project called Grande Ourse, which is really intended for psychoeducation—for example, connecting women with various resources across the province, one of which is the Québec Alliance for Perinatal Mental Health. Another well-known resource is Réseau des Centres de Ressources Périnatales du Québec, under the guidance of Marie-Claude Dufour. There are already initiatives there to allow women to be connected, whereas if you look at other institutions, you will not find that.

I think that points to the fact that even when there are the best of intentions to provide care, because there are no clear guidelines in terms of what to do, there are discrepancies not just among provinces, but even within provinces and institutions themselves.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Montreuil.

Mrs. Brière now has the floor for six minutes.

[Élisabeth Brière, Liberal, Sherbrooke, QC]

Thank you, Mr. Chair.

Thank you to all of our witnesses for being with us this afternoon.

Ms. Montreuil, my first question is quite simple. What time frame does the perinatal period cover?

[Dr. Tina Montreuil]

As I said at the start, it starts at conception and lasts until about 12 months after delivery, or roughly until the child's first birthday.