Health Committee on April 11th, 2024

[The Chair, Liberal, Sean Casey]

I call this meeting to order.

Welcome to meeting number 109 of the House of Commons Standing Committee on Health.

I would give a friendly reminder to everyone to ensure that you put you earpiece a bit of a distance from the microphone so that it doesn't cause feedback and potential injury.

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

Before I welcome our witnesses, I want to provide this trigger warning. We will be discussing experiences related to violence and assault. This may be triggering to viewers with similar experiences. If you feel distressed or if you need help, please advise the clerk.

I would like to now welcome our panel of witnesses. Appearing as an individual, we have Dr. Nichole Fairbrother, clinical associate professor, department of family practice at the University of British Columbia. On behalf of the Centre for Addiction and Mental Health, we have Dr. Liisa Galea, senior scientist and Treliving chair, women's mental health. Representing the Kawartha Sexual Assault Centre, we have Jocelyn Enright, coordinator, community engagement, communications and fundraising. On behalf of Persons Against Non-State Torture, we have Linda MacDonald, co-founder, and Jeanne Sarson, co-founder.

Welcome to all of our witnesses. You'll have five minutes for your opening statements.

We'll begin with Dr. Fairbrother.

[Dr. Nichole Fairbrother, Clinical Associate Professor, Department of Family Practice, University of British Columbia, As an Individual]

Good morning. Thank you very much.

I'm aware from colleagues that women's mental health encompasses a broad range of conditions that others have already spoken about this week, so in my five minutes I'm going to focus on my own areas of knowledge and expertise. I'm going to discuss with you two key topics in this area: postpartum thoughts of infant-related harm and their relationship with infant safety and mental health, and perinatal anxiety and anxiety-related conditions.

To begin, 99% of new parents report unwanted and intrusive thoughts of one's infant being harmed by accident, and over half of new parents report unwanted intrusive thoughts of harming their infant on purpose. This is not generally known, and understanding of this phenomenon is limited. This lack of knowledge has significant negative consequences for parents and their infants.

We now have superb data showing that, when unwanted and intrusive, thoughts of harming one's infant on purpose are not associated with an increased risk of violence toward the infant. They are, however, associated with significant distress and an increased risk of mental health difficulties, the most common of which are obsessive-compulsive disorder and depression.

Health care providers are understandably concerned when a parent discloses thoughts of harming their infant. However, a lack of knowledge in this area often results in unnecessary referrals to child protective services, monitoring for child abuse and, on occasion, child removal. These actions are necessary when there is a real risk to infant safety. However, when not necessary, these dramatic actions can have devastating consequences for parents and their infants.

In this area, I recommend that we develop and evaluate education for care providers to improve their knowledge and management of these disclosures of harm thoughts; that we seek to understand and mitigate the negative consequences of disclosures of postpartum harm thoughts by parents to care providers, in particular for indigenous parents; that we assess the effectiveness of education regarding postpartum harm thoughts in reducing their mental health consequences; and that we learn more about the experience of postpartum harm thoughts by fathers and parents of other genders.

With respect to anxiety and anxiety-related disorders, there are more than 10 such conditions. They disproportionately affect women, and, as a group, are the most prevalent of all mental health conditions. They are also associated with significant distress, life impairment and increased health care costs.

For convenience, I will refer to anxiety and its related conditions collectively as anxiety disorders.

Of pregnant and postpartum people, 21%, or one in five, suffer from one or more of these disorders. They are of particular importance during the perinatal period, because they also negatively impact infant and fetal development. For our health care system to respond effectively to people suffering from these conditions, we require accurate and effective screening, assessment and treatment.

Outside of reproduction, we have excellent psychosocial and medication treatments. Talk therapy—in particular cognitive behavioural therapy, CBT—is the treatment of choice for many of these conditions. CBT is typically as effective as medication at the conclusion of treatment and superior at follow-up and preventing relapse. However, publicly funded CBT is extremely limited; consequently, frequently only those with third party medical coverage, or the means to pay high out-of-pocket costs, are able to access treatment.

Among perinatal people, there is a high acceptability of screening, and talk therapy is strongly preferred to medication. Pregnant people especially need access to evidence-based talk therapy for their mental health due to concerns about the potential negative impact of psychotropic medications on the developing fetus.

My recommendations in this area are to increase research to identify accurate and reliable screening tools for perinatal anxiety disorders, to assess the impact of mental health screening on mental health outcomes for both perinatal depression and anxiety, to assess the effectiveness of CBT in perinatal populations and to identify low-cost ways of increasing CBT access for perinatal people in particular. Generally, I think increased funding specific to perinatal mental health would be very beneficial.

Thank you very much for your time.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Fairbrother.

Next, from the Centre for Addiction and Mental Health, is Dr. Liisa Galea.

Welcome to the committee. You have the floor.

[Dr. Liisa Galea, Senior Scientist and Treliving Family Chair, Women's Mental Health, Centre for Addiction and Mental Health]

Thank you, Mr. Chair, and honourable members.

I've been a professor for over 25 years, first at the University of British Columbia, and now at the Centre for Addiction and Mental Health and the University of Toronto. I'm also scientific lead of womenmind, which is at the Centre for Addiction and Mental Health, and the lead of the women's health research cluster, which has over 570 members in 29 countries worldwide. Both of these initiatives have common goals dedicated, in part, in closing the gender gap in science by putting the unique needs and experiences of girls and women at the forefront of mental health research.

As a neuroendocrinologist, my research is on how estrogens and stress influence female mental health across the lifespan from a biological perspective. My driving questions have been around why women are more likely to be diagnosed with depression and Alzheimer's disease compared to men. What is it about our brains that make us more susceptible to these disorders?

Indeed, we and others have found numerous molecular signatures in the brain that differ by sex and female-specific experiences, and underscore the vital importance of continuing this work, because one size does not fit all when it comes to mental health interventions.

Beyond understanding sex influence on disease, I have been studying how female-specific experiences, such as pregnancy, menopause and hormonal contraceptives, influence the brain. The time of greatest risk for first-time depression is during postpartum and in perimenopause. However, these female-specific experiences are rarely considered in the literature. How rare is that? We found that only 3% of neuroscience and psychiatry studies have examined women's health questions. Indeed, there were nine times more studies on males compared to females.

I'm a highly cited scientist, top 2% in the world and I have over 200 publications, but it has been very challenging to get the research funding to do work in this area. My experience is not unique. Many of us have had comments on our grants, saying to “add men” or “add males”. This is for grants that centre on pregnancy, placenta or female-specific cancers. We need women's health research; without the research, we can't tell our health care providers where to steer the boat as our research discoveries are our compass and map.

Yet, although attention to the lack of equity in health research is improving, most of it is directed towards sex and gender differences in disease and health. We need to understand that specific research on women's health and female-specific variables across the lifespan is crucial for improved mental health outcomes.

Women's health research has been undervalued, understudied and underfunded. Not only do females and women have a unique physiology and experiences that impact their health differently from men, many women experience them differently at different times in their lives than men. Ignoring these differences, it becomes more difficult to accurately diagnose and treat these conditions.

Another large study found that for over 980 different disorders, women were diagnosed 3.7 years later than men for the very same disease. This was true for mental health disorders, Alzheimer's disease and more. A fundamental reason for these disparities is that most of our medical knowledge, including our diagnosis criteria, is based on the data and experiences of men.

This has led to the labelling of symptoms in women as atypical. This atypical label is seen across a wide variety of disorders, including depression, anxiety, bipolar disorder and autism. It's only atypical when you compare it to men. It's not atypical for the roughly 50% of our population. Words do matter. This atypical label likely contributes to the delay in diagnosis. We know that earlier diagnosis leads to earlier interventions and improved outcomes.

In another study we did, we examined over 8,000 Canadian grants across 11 years. We found that less than 6% of federal funding went towards women's health research. A recent World Economic Forum report suggested that we could save one trillion dollars a year worldwide if we invested in women's health research. The U.S. government is promising $12 billion for women's health research.

When funding for specific issues is protected, amazing discoveries are made. Consider the ALS ice bucket challenge that raised $115 million for ALS 10 years ago. This investment has more than doubled the number of researchers and publications, and increased the number of clinical trials 10 times, such that now we have at least four new approved treatments.

I recommend a concerted national investment in women's health research as this is necessary for improving women's mental health outcomes. Only when society values women's health factors, and pays more attention, will we be able to realize the promise of precision medicine.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Galea.

Next, from the Kawartha Sexual Assault Centre, we have Jocelyn Enright.

Welcome to the committee. You have the floor.

[Jocelyn Enright, Coordinator, Community Engagement, Communications, and Fundraising, Kawartha Sexual Assault Centre]

Thank you.

It's an honour to present today to the standing committee to speak on the health of women and girls.

My name is Jocelyn. My pronouns are she/her. I work at a small sexual assault centre in Peterborough, Ontario that receives around $340,000 in core funding from the provincial government under the Ministry of Children, Community and Social Services.

I will share that our centre does support survivors of any gender; however, I am going to focus on our supports for women and girls today.

I would like to highlight the significant impact that sexual violence has on the health of women and girls, including trans women and all other women members of the 2SLGBTQIA+ community. I will discuss the need to mitigate long-term mental health concerns for survivors, the need for more preventative measures and the need for more core funding to accomplish these goals.

Women survivors of sexual assault are more than twice as likely as male survivors to develop post-traumatic stress disorder, PTSD, with symptoms lasting up to four times longer than males, even when controlling for the extent of trauma exposure and the type of sexual assault experienced.

According to the DSM-5, some of the highest rates of PTSD are found among rape survivors, with rates ranging from one third to over one half. Symptoms include re-experiencing the traumatic event through flashbacks and nightmares, avoiding reminders of the traumatic event, startling easily and experiencing negative thoughts and beliefs that impact daily living.

PTSD is commonly associated with many other health and mental health disorders and is not the only mental health condition that may develop after sexual assault. Survivors may also develop generalized anxiety disorder, major depressive disorder, suicidal ideation, self-harm behaviours, chronic pain and chronic health conditions, eating disorders and body dysmorphia, obsessive-compulsive disorder and dependence on substances as a means of coping.

Many women may also receive diagnoses of personality disorders like borderline personality disorder after experiencing trauma, disorders that carry heavy stigma and may lead many programs to deem their cases too complex. Researchers suggest that there is an overdiagnosis of personality disorders in women who have been sexually assaulted particularly and advocate for diagnoses of complex PTSD instead.

The risk for these related mental health conditions may be greater for individuals who experience sexual assault at a younger age. Early trauma can cause disruptions of neurotransmitters and negatively impact brain development. Trauma changes the connections and wiring in the brain and may influence our ability to process and regulate emotions later on, symptoms often associated with said personality disorders.

Complex PTSD is often seen in women who have experienced multiple sexual traumas or experienced sexual trauma early in childhood. Girls who experience childhood sexual abuse, CSA, are at an increased risk of being sexually assaulted in adolescence and as adults, further increasing their risk of developing further mental health disorders.

It is important to note that unfortunately our centre is not funded to serve clients under age 16. This leaves a significant gap in services for girls. Where do we send them if they don't have money for private therapy or we don't have other agencies in our area that specialize in supporting sexual assault survivors? We have many folks come to our door as adults who are looking for support for their experiences of childhood sexual assault specifically. Imagine how much more we could do for these survivors if they could access our services and supports immediately after experiencing childhood sexual assault. Imagine the ease that would have on all health resources down the line if we could mitigate that trauma rewiring before it becomes ingrained and mitigate the development of all of those other mental health disorders. Imagine if we treated complex PTSD in women and girls instead of labelling them with stigma later in life.

Our agency services four large counties around Peterborough, and 2021 census data estimates around 336,864 residents are in our catchment area. Even just looking at women and girls alone, that's a lot of people, and I'll note that our core funding supports pay for one management role, one admin role, one prevention educator and one counsellor.

Women who are believed and not blamed and offered trauma-informed support after a sexual assault are less likely to develop these long-term mental health impacts. The sexual assault centres across Ontario and elsewhere in Canada are extremely underfunded. If more core funding was invested into these agencies, survivors of sexual violence would get better access to supports in a timely manner, which would prevent many instances of these long-term disorders.

Prevention education also needs to be prioritized. In Ontario a lot of sexual assault centres cannot take on this role for lack of capacity and funding or take this role on with limited funding. If we can teach young boys early about the core foundations of sexual violence, consent, masculinity and their patriarchy, we will see rates of sexual violence decrease over time.

Right now our funding provides us with the bare minimum to provide band-aid solutions to women, often long after the harm has taken place, and neglects the power of prevention in creating lasting change.

We work tirelessly to make the world as safe a place as possible for women and girls, but the reality is that we are dramatically underfunded to do so. Providing additional core funding to sexual assault centres will have a great impact on the future of women and girls, and on their health and mental health. The federal government can play a role in this by advocating to the provincial government for additional funding, and it can look to federally funded programs like Public Safety's end gender-based violence plan to help support that core funding.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you, Ms. Enright.

Next up is Persons Against Non-State Torture.

Welcome.

[Linda MacDonald, Co-Founder, Persons Against Non-State Torture]

Thank you.

I'm Linda MacDonald and this is Jeanne Sarson. We are from Persons Against Non-State Torture and members of the National Council of Women of Canada. We are retired public health nurses and grassroots feminist activists.

For 31 years, we have supported women in Canada who have been subjected to torture by non-state actors—non-state torture. This started with one woman in our community in Nova Scotia. We proudly bring these women's voices. Many have endured non-state torture from infancy onward, and they have all endured grave discrimination.

Non-state torture is torture that occurs in the domestic or private sphere in relationships perpetrated within families and in human trafficking, prostitution, pornographic exploitation, and violent groups and gangs. It is dismissed as socio-cultural, traditional or religious acts or norms, and it can be committed through migration, displacement and humanitarian unrest.

Non-state actors, as defined by the UN Security Council, are any individuals or entities “not acting under the lawful authority” of the state.

Acts of non-state torture are intentional and can include mental or physical severe pain and suffering through electric shocking, water torture, forced drugging, group or gang rapes, beatings, whippings, cutting, burning, forced impregnation and abortions. Because Canada's Criminal Code lacks a law against non-state torture, women are invisiblized, pathologized and mislabelled as mentally ill. Their normal response to non-state torture is seen as a disorder, and discrimination prevents them from receiving the proper mental health care they need to heal with dignity from such serious crimes and human rights violations.

A simple example is Sara, a survivor of non-state torture getting blood work done at our local hospital. Seeing blood tubes in the elevator, she got triggered and fell to the floor. The hospital staff misunderstood her response. They placed her on a stretcher with raised side rails and she was watched by a uniformed commissioner, who stopped her from escaping. After eight hours, she called us to the hospital and we helped settle her. If the staff had understood that this is a normal response to the terror of seeing her own blood, this eight-hour ordeal could have been prevented.

Using our own victimization- and traumatization-informed model of care, we have been successful in helping women heal from non-state torture.

[Jeanne Sarson, Co-Founder, Persons Against Non-State Torture]

I will continue and I will offer evidence-based and victim-centred research.

We are not alone in identifying and understanding the mental health differences between non-state torture and assault or abuse victimizations. Our research questionnaire asked citizens whether 48 violent behaviours were indicative of assault, abuse or non-state torture, if many or all were inflicted on one person.

Of 776 respondents, 723 or 93% were Canadian, 680 or 88% were female respondents, 89 or 12% were male, seven didn't answer or said “other”, 7% were from other countries and 8% came via our website or regular mail.

This questionnaire also asked, “If you were forced to choose between being a victim of abuse/assault or a victim of torture, which would you choose?”

Some 680, or 88%, chose assault or abuse, explaining that non-state torture was more life-threatening, more dehumanizing, more painful and more difficult to heal from and that they were disbelieved. Some 6% were undecided or did not answer and 6% chose non-state torture.

As two women explained, that's all they knew. One woman said that she was brought into a child sex-trafficking ring by her father when she was around the age of four. She said that most of what she was put through in this ring she considers to be torture and that she is still having powerful flashbacks, which include body memories of this torture.

The other woman said that she was definitely tortured. She said that she uses this term to help health care professionals and others understand her childhood and not minimize it.

Our three recommendations are to criminalize torture perpetrated by non-state actors as a torture crime; to recognize non-state torture victimization-traumatization informed care; and that education on violence against women must include non-state torture victimization.

Women cannot mentally heal when social-political injustice dehumanizes them as persons with no legal right to truth-tell, when they are not treated with dignity, when they are disbelieved and when they are not protected from non-state torture.

Thank you for your time.

[The Chair, Liberal, Sean Casey]

Thank you.

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

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

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

Thank you, Mr. Chair.

Thank you, to all the witnesses. I commend you. Your work is so important. I applaud you.

I am going to start with Linda and Jeanne.

I have to tell you, if you haven't read their book, don't read it at night before you go to bed. I'm going to quote a few things because I want to get to the torture part. I think this non-state and state torture is not fair.

I am going to start with a quote on page 15 of your book.

Sara said that there's “'no hope for people like me.'”

On page 27 is a quote from Sara, who said that her “'father was using her for his friends' and her aunt was 'making her sleep with her son and making them do things while she watched.'” She said, “'dogs were used.'”

On page 33, it states that in 1991, “the world did not acknowledge such dehumanizing brutality as non-State torture, as a form of violence being inflicted on girls and women within family relationships.”

It continues on to say, “Sara feared she would Self-harm if she could not” get out. She kept repeating, “'Get it out. Get it out'...[which] meant all the crimes perpetrated against her. She said, 'I know they didn't want me to die because I was their commodity.'"

I could go on and on. There are many quotes that really touched me when I read through a lot of information in your book.

One thing that really shocked me was when she said, “'big people, adults! Ministers, gov't worker, cops, pilots...basement orgies like other people having parties or Tupperware, etc.,' and of being 'taken way back in woods and tortured and raped continuously.'”

The study we're conducting today is on women's mental health, so let me ask you this: If a woman has suffered horrible atrocities at the hands of a family member, a spouse or a stranger and the Canadian legal system does not acknowledge that what she has been put through is torture, what would that do to a woman's mental health?

For example, gang rape has been acknowledged by the United Nations as torture, but the Canadian Criminal Code does not.

What happens to the woman's mental health when she finally has the courage to step up and name her torturer and the legal system says, “No, you didn't experience torture”?

I'll leave it to Linda or Jeanne to answer, please.

[Jeanne Sarson]

What happens to them? Well, when Sara came to us in 1993, Linda and I had no idea that torture happened in families. What we learned is that they survive by disassociation. Sara did not know she was a human being. When we said to her, “Sara, you're a human being,” she said that nobody ever told her that. She thought she was an “it”. That's how she explained herself as a human being: as an “it”.

When trying to heal, some women, Sara included, would often want to hold our hands. Sara would say that she could not feel any sensation. This is because, in order to survive, they have to cut off their senses. They cut off their sense of smell. They cut off their physical sense, and they cut off their visual sense. I was sitting outdoors with Sara one day in the fall, and all of a sudden she said, “Look at the trees; they're turning colour.” She said that she had only seen in black and white. We see that over and over again.

When you reference the issue to get out, it was the fact that the torture memories were so heavy. If they're not listened to, they don't know what else to do. As other people have said here, they start cutting, and they're self-drugging. They have difficulty with the food they eat. Sara was also taught by her parents to, if you will, die by suicide. When she was a little girl, they used to put her—and this is her telling—in the hallway and teach her how to cut her wrists if she ever told.

When we met her, she was almost 30 years old. She was a professional, had a professional job and was still living two lives. People seem to not understand that. However, we know that, in domestic violence, women go to work and then go home and get beaten. She was a professional. She went to work. She went home and even at almost 30 was still being tortured, was still being trafficked and still did not understand that what she was living was violence.

What we have to understand is that it takes time for them to understand what they've been going through. She was a baby, and the torture started then.

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

I just want to say one thing because I know I don't have a lot of time.

There was a quote on page 43 that read, “I have lived my life doing what others wanted me to do with the hope they might love me or come to care for me even a little.” I want to thank you, Jeanne and Linda, for saving her because reading this book has taught me a lot. Non-state torture and torture are very similar. How can a country like Canada not look at this as torture? This woman who you were able to save today was tortured.

Go ahead, Linda.

[Linda MacDonald]

What I want to do is explain how Sara and all the women feel because there's no law in our country.

It's one thing to be dehumanized by your family or traffickers, or in prostitution or pornography. However, it's another to be dehumanized by your country. They are told by their country that.... Sara endured 20,000 rapes by the age of 20. If we want to call that assault in our country, that is a grave injustice to her. It reinforces that she's an “it” and that nobody will ever believe her. How do we say that women in conflict who are gang-raped were tortured but that in our country for Sara, who was gang-raped, or for women who were gang-raped after a hockey game, it's assault and not torture? The injustice is that we're telling them that they're not as important. It's a form of discrimination that they live with every day.

[The Chair, Liberal, Sean Casey]

Thank you. That's your time.

Ms. Sidhu, you have six minutes, please.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you, Mr. Chair.

Thank you to all the witnesses. Hats off to you for the work you are doing for all women, and keep up the good work. Thank you for your insightful testimony.

Dr. Galea, in your testimony, you talked about women being behind. There are nine times more studies on men than on women. What barriers are you seeing? What are the recommendations that you can provide to us today on how we can help in this matter?

[Dr. Liisa Galea]

I think my personal opinion and recommendation is to have protected ring-fenced funding for women's health in general, and for the research, because when you protect the funding for research in a specific area, multidisciplinary researchers will write the grants and do the research in that particular area. If we leave it open to saying.... Right now in the federal grants, there's a lot of attention paid to sex- and gender-based analysis, which is fantastic and laudatory, and they'll tell you that 90% of their grants are doing this, but they've analyzed a mandatory box that we all have to fill out.

We actually analyzed what they said they were going to do, and that's when we found that only.... If you exclude female breast cancer, I think it's 4.4% of federal grants that are going towards women's health questions. I can't tell you all of it. I can just tell you my experience: that it is very undervalued. Part of the reason why I wanted to start the women's health cluster was to empower researchers to do this kind of work. I have heard from women's health researchers that they don't want to call themselves “women's health researchers”, because they feel it's undervalued.

As I said, I get questions. One of the things we do in my lab is postpartum depression research, and I've been told multiple times in trying to publish it or trying to get grants that this isn't important research, even though we know that in a person's lifetime it is the time of greatest risk to develop depression.

I think ring-fenced funding, like ALS and the ice bucket challenge.... Another one is HIV/AIDS. There was lots of money, which the Canadian government gave worldwide, and it went from a death sentence to people being able to live with the infection now.

That's the solution to me. That's our compass and map.

[Sonia Sidhu, Liberal, Brampton South, ON]

There is one other point I want to mention. You said that 3.7 years later a diagnosis is seen.

[Dr. Liisa Galea]

Yes.

[Sonia Sidhu, Liberal, Brampton South, ON]

Is this again something on the lack of data or lack of the research funding or a different diagnosis? What is it?

[Dr. Liisa Galea]

I think that's a really fantastic question. I think it's all those things. There are going to be things on the biological side of things. There are going to be things on the social side of things as well. We talk about the “D's” and the “U's”: the denial, the dismissal, the delay, the diagnosis, and the understudied, the undervalued and the underfunded. A number of diseases and disorders do manifest differently, right? That's where we get that “atypical” label from.

Also, in another big one, there was a story just recently about a woman in her forties having a heart attack. They didn't recognize the symptoms, because one of the major symptoms is that they don't feel well. You've probably seen the stories: They go to the ER and they get prescribed anti-depressants. I think that's a big part of it. We don't recognize that the symptoms can be quite different, and that likely means that the manifestation brain-wise or body-wise is also quite different and requires different types of treatments. It's unfortunate.

Of those 3,000 studies, we also looked to see, did they analyze by sex or gender...? First of all, there was very little work on gender in general in the journals we looked at: It was 3% of studies—

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you.

We've heard that with the way perinatal classes are structured right now mental health is often overlooked or not talked about. Can you tell us how the training for future parents could be improved?

[Dr. Nichole Fairbrother]

Could you just clarify your question, please?

[Sonia Sidhu, Liberal, Brampton South, ON]

In the perinatal classes and how they are structured right now, mental health is often overlooked or not talked about. How could the training for our future parents be improved for these classes? Or is there anything missing from these classes? You can talk about that.

[Dr. Nichole Fairbrother]

I'd like you to go first, Dr. Galea. I can finish up, but I think you probably know a bit more about perinatal classes than I do.