Comprehensive Maternal Child Health Care

in

First Nations and Inuit Communities:

A Discussion Paper

Office of Nursing Services

First Nations and Inuit Health Branch

Dawn Smith, RN, MN

Population Health PhD student

August 8, 2002

Number range CHAPTER**Table of Contents**

Page Number

-   Executive Summary 4

**Why is Maternal Child Health Care Important to the Vitality of First**

**Nations and Inuit Communities? 5**

The Purpose of this Paper 6

The Framework and Methodological Approach 6

**What is Maternal Child Health Care? 8**

**Structures and the Policy Context: What is the Crux of the Problem?**
**9**

Maternal Child Health Services 11

Related Maternal/Child and Family Health Programs on Reserve 11

What are System and Program Challenges? 11

What is the impact of medical evacuation as the cornerstone of maternity
care? 12

Who is the Target Population and Where do They Live? 13

Aboriginal Health Status Issues Impacting on Maternal Child Health Care
14

**Values: A Vision and Goals for Maternal Child Health Care on Reserve
15**

Aboriginal Values 15

Evidence Linking Maternal Child Care and Long Term Health Status 16

Early brain development 16

Attachment 16

Standards for Maternal Child Health Care 17

> Synthesis of Values for New Maternal Health Policy on Reserve 17
>
> Ethical Health Care 17
>
> Culturally Safe Health Care 18
>
> Community Determined/Designed 19
>
> Equitable Health Care 19
>
> Multidisciplinary 20

**Information: Synthesis of Evidence for Effective Interventions 20**

> Community control or involvement 20
>
> Cultural safety or appropriateness 20

Development of a Trusting Relationship with a Primary Care Giver 21

> Home Visiting /Multiple Intervention Approach 21

Disciplinary Issues 21

Adequate Support for Implementation and Evaluation 22

Experiential Evidence: Alternative Models of Maternity Care 22

System level initiatives /models 22

Midwifery and Aboriginal Midwifery Models 24

Birthing Centers 24

**Limitations, Recommendations and Next Steps 24**

Limitations 24

Recommendations 25

Program Design 25

Program Implementation 26

Program Evaluation 27

Recommendations for Research 27

Next Steps 28

**Conclusion 28**

-   References 30

-   Figures 37

-   Tables Not in the Text 46

-   Appendices

Appendix A: Stakeholder Consultations 49

Appendix B: Synthesis of Evidence for Maternal Child Health Care
Intervention 51

**List of Tables and Figures**

**Page**

[Tables]{.underline}

Table 1: Defining Maternal Child Health Care (in text) 8

Table 2: Health Services Available in On Reserve Communities (in text)
10

Table 3: Prenatal and Postnatal Services Described in Regional Program
Manuals (in text) 11

Table 4: Examples of the Impact of Evacuation on Health (referred to on)
12

Table 5: Number and Percentage of Status and Non-Status Population

Living on Reserve by Type of Community 2002-2003 (in text) 14

Table 6: Selected Maternal Child Health Indicators (referred to on) 14

Table 7: Principles of Human Rights for Ethical Health Care (in text) 18

[Figures]{.underline}

Figure 1: Sabatier-Lomas Policy Making Framework (referred to on) 6

Figure 2: Safe Motherhood Framework for Assessing and Analyzing

Maternal Health (referred to on) 8

Figure 3: Relationship Between Community Birthing Capacity and

Community Sustainability (referred to on) 13

Figure 4: Geographical Distribution of Aboriginal Population, 1996
(referred to on) 13

Figure 5: Pathway of Effects Between Perinatal Development and

Life Long Health (referred to on) 16

Figure 6: Emphases in Quality Maternal Child Health Care (referred to
on) 17

Figure 7: Stakeholders to Maternal Child Health Care on Reserve

**Executive Summary**

Concerns about the maternal evacuation practice from Aboriginal people,
health professionals, and nursing policy makers precipitated examination
of maternal child health care on reserve. A background paper on this
issue was initiated by the Office of Nursing Services, First Nations and
Inuit Health Branch of Health Canada, in collaboration with the Society
for Obstetricians and Gynecologists of Canada's research and policy
division and its Aboriginal health committee. The aim of the paper is to
lay out the issues, information and evidence necessary for informed
dialogue between stakeholder groups. It focuses on answering the
questions: *What are the values and issues related to maternity care in
rural and remote on reserve First Nations and Inuit communities? What
opportunities and challenges are suggested by the evidence and the
structures for delivering high quality culturally safe maternity care in
on-reserve First Nations and Inuit communities in Canada? What can we
learn from the experience of other jurisdictions?*

The Sabatier-Lomas policy making framework was used to guide collection
and description of the information, values and structures impacting on
this issue. A strong emphasis was put on collecting the evidence on both
the impact of peri-natal development on health, and on effectiveness of
interventions focused on improving peri-natal outcomes. The evidence on
the determinants of health established that adequate support and
intervention during the peri-natal period has a lasting impact on the
health and vitality of individuals, families and communities.

This initial analysis found that current maternal child health care in
on-reserve First Nations and Inuit communities falls short of national
and international standards. The existing policy relies heavily on
evacuation of women in late pregnancy for "medically safe births", and
has minimized attention to key factors influencing peri-natal health and
development. The current policy is complicated by an unstable workforce
and poorly developed management and health information system as well as
the challenges of isolated communities, increased prevalence of
peri-natal risk factors in the Aboriginal population, and the current
shortage of health professionals. The result is that current maternal
child health care defaults to crisis oriented intervention on urgent
problems, and little time or resources available for health promotion
and preventive care that is so critically important during the pre and
post natal periods. Continuity of care is also compromised due to high
turnover of on-reserve nursing staff.

The evidence for intervention is congruent with stakeholder values
regarding maternal child health care. Both evidence and values call for
a comprehensive system of care focused strongly on health promotion and
prevention from preconception to post partum. Effectiveness was found to
be enhanced when program design was: community driven, culturally safe,
delivered by a multidisciplinary team, focused on early recruitment, and
development of a trusting relationship with women and their families.
Adequate resources, ongoing training and support, effective information
management, well developed protocols for transfer between health care
organizations, and community involvement were deemed important to
program implementation and evaluation.

The result is a clear picture of how and why maternal child health care
in on reserve communities can be improved. Recommendations for program
design, implementation and evaluation are suggested. Several
recommendations for research are included. Suggestions for next steps in
the policy development process are pointed out.

**Why is Comprehensive Maternal Child Health Care Important to the
Vitality of First Nations and Inuit Communities?**

A successful experience from preconception to the early months of the
infant's life, has a significant and long lasting impact on health
status for the mother, the foetus, the family and the community. Perhaps
more than any other group in Canada, Aboriginal people need the benefits
to individuals, families and communities that are afforded by giving
children a strong start in life.

Intervention during the "early years" is key to improving long term
health status and to breaking the cycle of poor health in Canada's
Aboriginal population. Early intervention to support neurobiological
development influences the integrity of the biological pathways that are
essential to life-long health and vitality. Research results have
demonstrated that the quality of maternal child health care has
immediate and long lasting effects on health status and quality of life
across population groups and settings. This forms a foundation for other
health programs (such as programs targeted at fetal alcohol syndrome,
prenatal nutrition, immunization, early childhood development, etc.) to
achieve maximum impact. Improving the maternal, social and cultural
environment of the fetus and newborn has perhaps the greatest potential
for developing strong and healthy people capable of socially and
economically productive lives. Yet, this same period is the most
vulnerable time for the fetus -- one in which gaps in care can lead to
developmental failures that last a life time.

Contemporary maternal child health care in most Canadian communities is
based on advances in medical, nursing, and midwifery knowledge and
practice, evidence related to the determinants of health, and evidence
of effectiveness of peri-natal interventions. Advances in telehealth
technology have reduced the geographic barriers to specialized knowledge
needed for safe care. According to the principles of the Canada Health
Act (1984), Aboriginal people deserve access to these advances in
maternal child health care practice. Aboriginal leaders and health care
experts have acknowledged that health inequities experienced by
Aboriginal people must be addressed using the best evidence of
effectiveness.

Yet current maternal child health care in on-reserve First Nations and
Inuit communities falls short of the standards set for the majority of
the country. The existing policy of evacuation of women in late
pregnancy for "medically safe births" has minimized the importance of
personal and community supports, quality pre- and post- natal care, and
the role of a trusted care provider in supporting women, families and
communities through the challenges of pregnancy, birth, and new
parenthood. The existing policy is complicated by the current health
human resource problems that tend to focus intervention on immediate,
crisis oriented primary medical care. This reduces available nursing
time and resources for the health promotion and preventive care that is
so critically important during the pre and post natal periods. The
disruption in care imposed by the evacuation policy also compromises the
effectiveness of linkages with relevant community services, such as the
fetal alcohol syndrome prevention, and nutrition programs. Lack of
adequate protocols following women through the evacuation process,
result in interruptions in continuity of care. Moreover, this
'downstream', crisis oriented approach is divorced from the cultural,
personal, family and community context essential to a successful
pregnancy and birth experience. It fails to address the root causes of
poor health experienced by women and families, and **compromises
Aboriginal peoples' efforts to achieve vitality in their families and
communities**.

The health, economic and cultural costs to women, children, families and
communities of this policy must not be overlooked (Young, Lee

s and Twaddle, 1997). Moreover, opportunity costs and potential
downstream costs related to not implementing the alternatives (what is
considered best practices in maternal child health care), to the health
care system, as well as the women and her family need be considered.
Finally, a comprehensive economic analysis should consider the costs to
the social welfare system, the education system and the justice system
when children start life with a care deficit.

[The Purpose of this Paper]{.underline}

"In (policy) decision-making, the first step is to establish the values,
and hence the goals that are being sought. The second step is to find
means for achieving those goals" (Butcher, 1998, p. 264). The aim of
this paper is to lay out the issues, information and evidence necessary
for informed dialogue between stakeholder groups working collaboratively
through these steps to develop a new maternity care policy for on
reserve Aboriginal communities. It focuses on answering the questions:

-   *What are the values and issues related to maternity care in rural
    and remote on reserve First Nations and Inuit communities?*

-   *What opportunities and challenges are suggested by the evidence and
    the structures for delivering high quality culturally safe maternity
    care in on-reserve First Nations and Inuit communities in Canada?*

-   *What can we learn from the experience of other jurisdictions?*

    The paper will attempt to describe the information, structures and
    values influencing maternal child health care in on reserve
    Aboriginal communities. To answer the above questions, and describe
    the considerations to be included in stakeholder deliberations on a
    new policy, the paper outlines:

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-   Why is a new maternal child health care policy for on reserve
    Aboriginal communities important?

-   The framework and methodological approach used in this analysis

-   A definition of maternal child health care

-   The policy context: what is the crux of the problem? In this section
    the policy context and service delivery system are described. The
    issues influencing the nature and the impact of maternal child
    health care currently being delivered to on reserve Aboriginal
    communities are listed. The characteristics of the environment and
    population that may influence the nature and quality of care being
    delivered are outlined.

-   The values underpinning a vision and goals for maternal child health
    care in on reserve Aboriginal communities are described next.

-   A synthesis of the scientific and experiential evidence for
    intervention and other jurisdictions' experience is briefly outlined
    in the third section.

-   The final section describes limitations, recommendations, and
    suggestions for next steps.

    [The Framework and Methodological Approach]{.underline}

    The Sabatier-Lomas Policy Framework was used to guide exploration of
    this topic in this population group and policy context **(See Figure
    1: Sabatier-Lomas Policy Framework)**. It facilitated the need to
    synthesize the different values and approaches to change of the
    various stakeholders, with the information and structures involved
    in delivery of maternal child health care to Aboriginal people
    living on reserve. This framework facilitated integration of
    rational empirical methods favored by policy makers, with the ways
    of being and values of Aboriginal people, and the strengths and
    perspectives of a multidisciplinary group of health care providers.

    The FNIHB Office of Nursing Services sought partnership with key
    stakeholders and resource people in Aboriginal health and maternity
    care to shape and facilitate this policy synthesis. These
    stakeholder organizations collectively contributed expertise in
    rural and remote midwifery, medicine and nursing practice, policy
    and research in Aboriginal communities, as well as understanding and
    advocacy for a culturally determined process. *The scope of this
    initial scan precluded involvement of women, families, community
    leaders and front line care providers in rural and remote Aboriginal
    communities, but considers their perspective as integral to
    development beyond this initial policy synthesis phase.*

The paper outlines the 3 main components involved in policy change:
information, structures and values (Lomas, 2000). Information describing
the characteristics of the environment and population was requested, and
to a lesser extent retrieved. A call was put out, through personal
interview, telephone consultation, email requests and telephone
follow-up, to the regions to obtain the most current and complete
information.

Scientific and experiential evidence for maternity care interventions
was identified through searching the published literature, and
networking with key informants in stakeholder organizations and
recognized experts in maternity care and Aboriginal health issues (**See
Appendix A: Stakeholder Consultations**). Evidence of effectiveness of
health promotion and prevention interventions, models and systems of
care during preconception and the perinatal period were the focus of the
literature search. The Cochrane Database of Systematic Reviews, Evidence
Based Medicine, Database of Reviews of Effectiveness, the Cochrane
Clinical Trials Register, the Health Technology Assessment Database of
the National Health System in the United Kingdom, the Effective Public
Health Practice Project Database of Systematic Reviews, Medline and the
Cumulative Index of Nursing and Allied Health Literature (CINAHL) were
first searched for 'family centered maternity care', and then widened to
maternity care to increase the pool of evidence. Specific searches for
systematic reviews related to infant attachment and breastfeeding
interventions were also conducted, based on preliminary synthesis of the
larger pool of systematic reviews and intervention studies. Studies and
reviews pertaining to specific aspects of medical management of
obstetrical complications or birth were not included. Limitations for
Aboriginal people were not applied as this significantly reduced the
pool of evidence available for review. As a result, the majority of the
evidence synthesized has limited generalizability to the specific
culture and context of on reserve communities.

Policy and program information, health status/demographic and health
services utilization data were sought from national, zone, and nursing
station level of the FNIHB, as well as some of the transferred Health
Authorities. Despite considerable effort and commitment on the part of
staff in selected regions, zones and nursing stations, a limited amount
of information was retrieved. This appears to be due for the most part
to system shortcomings, such as inadequate/unstable staffing and a
cumbersome and weakly supported information system at the field and zone
level.

Values are reflected in the vision and guiding principles for maternal
child health care in on-reserve Aboriginal communities. These were
developed through collection and synthesis of:

-   evidence on determinants of health to reflect current values
    regarding health care;

-   standards for maternal child health care valued and received by most
    Canadians; and

-   Aboriginal values regarding maternal child health, and health system
    change.

    The paper concludes with limitations and recommendations for
    maternity care policy and interventions were developed by weighing
    the recommendations from the evidence with the guiding principles
    and the characteristics of the population and environment.
    Recommendations for next steps in the development and implementation
    of a new maternity care policy for on-reserve Aboriginal communities
    are suggested.

    **What is Maternal Child Health Care?**

    Maternal child health care can be defined and implemented quite
    differently as is evident in the definitions in Table 1: *Defining
    Maternal Child Health.* Determining an attitude, and scope for
    maternal child health care is a key task for stakeholders and policy
    makers when developing a new policy. For example, the New Zealand
    Health Funding Authority (2000) vision stays quite focused on the
    period of time from conception to immediately after birth:

    Table 1: Defining Maternal Child Health Care

  --------------- -------------------------------------------------------
  Organization    Definition/Vision

  New Zealand     "*Each woman and her family has a safe and fulfilling
  Health Funding  outcome to her pregnancy and childbirth, through
  Authority       provision of programmes and services that are based on
  (2000)          partnerships, information and choice. Pregnancy and
                  childbirth are a normal lifestage for most women, with
                  appropriate additional care available to those women
                  who require it."* (p.10)

  Health Canada   *A complex, multidimensional, dynamic process of
  (2000) National providing safe, skilled, and individualized care. It
  Guidelines for  responds to the physical, emotional, and psychosocial
  Family Centered needs of the woman and her family. In family-centered
  Maternity Care  maternity and newborn care, pregnancy and birth are
                  considered normal, healthy life events. As well, such
                  care recognizes the significance of family support,
                  participation, and choice. In effect, family-centered
                  maternity and newborn care reflects an attitude rather
                  than a protocol (Rush, 1997, p.1, cited in Health
                  Canada, 2000, p. 1.8.*

  International   *Reproductive health is a state of complete physical,
  Conference on   mental and social well being, and not merely the
  Population and  absence of disease or infirmity, in all matters
  Development     relating to the reproductive system and to its
  (1994)          functions and processes.....Reproductive health care is
                  defined as the constellation of methods, techniques and
                  services that contribute to reproductive health and
                  well being by preventing and solving reproductive
                  health problems. It also includes sexual health, the
                  purpose of which is the enhancement of life and
                  personal relations, and not merely counseling and care
                  related to reproduction and sexually transmitted
                  diseases.*

  UNICEF (1999)   A framework describing the systemic, cultural and
  International   community level factors influencing maternal and
  Guidelines for  newborn health. This framework provides direction for
  Safe Motherhood intervention on the underlying causes of poor maternal
                  child health outcomes, rather than focusing exclusively
                  on the medical problems that surface during pregnancy,
                  birth and the post partum period **(See Figure 2: Safe
                  Motherhood Framework for Assessing and Analyzing
                  Maternal Health)**.
  --------------- -------------------------------------------------------

For the purpose of this paper, the **operational definition** of
maternal child health care includes interventions at individual, family
and community levels aiming to improve capacity for safe and healthy
pregnancy, birth and transition to parenting. It occurs from the
preconception period until several months past birth, when women,
infants and families are integrated effectively with early childhood
programs and services. Women of childbearing age are the key target for
programs and interventions, but neonates and infants, families and
communities are also the foci of intervention.

**Structures and the Policy Context: What is the Crux of the Problem?**

To assess policy performance related to maternity care, and identify
issues for consideration in future policy development, several questions
must be answered. First, what care is currently being provided, by whom
and where? What are system and program challenges impacting on provision
of care? What is the impact of current policies? Second, who is the
target population and where do they live? A clear idea of the
demographic characteristics and distribution of the on-reserve child
bearing population is needed. Relevant health status issues impacting on
maternal child health care needs and outcomes must also be considered.

The most current Government of Canada Indian Health Policy (1979)
recognizes the circumstances of many on-reserve communities that place
Aboriginal people at a

disadvantage compared to most Canadians in terms of health. The goal of
the policy is to "achieve an increasing level of health in Indian
communities, generated and maintained by Indian people themselves". The
policy states that health care must be built on 3 pillars: 1) community
development; 2) involvement of Indian people in planning, budgeting and
delivery of programs; and the 3) interdependent relationship between
federal government, provincial government and Indian communities
themselves in adaptation and delivery of public health, health promotion
and protection (federal government), and necessary diagnostic, treatment
and rehabilitation services (provincial government) (Government of
Canada, 1979).

A number of governments deliver health services to the First Nations
population: a) provincial and territorial governments, b) the federal
government through Health Canada, and c) First Nations local
governments. The federal government provides health services to on
reserve status Indians and to recognized Inuit as a matter of policy
through the First Nations and Inuit Health Branch (FNIHB). The FNIHB
objective is to assist First Nations and Inuit communities in addressing
health inequalities and disease threats and attaining a level of health
comparable with that of other Canadians living in similar locations, and
to ensure the availability of, or access to, health services (Auditor
General, 2001). Unlike other branches of Health Canada, FNIHB is
responsible for direct delivery of health services and other related
services to over 600 First Nations communities.

Maternal child health services are the responsibility of Community
Health Programs of the FNIHB, as well as the Non-Insured Health Benefits
program, which covers other benefits related to maternity care such as
prescription drugs and medical transportation. Community health programs
are delivered through separate contribution agreements and through
transfer agreements. Community health programs comprise programs and
activities related to public health, health education and promotion, as
well as strategies to address specific health problems such as alcohol
and drug abuse.

Descriptions of accessibility to communities, and levels of services
provided in each type of community is provided in Table 2: *Health
Services Available in On-Reserve Communities.*

**Table 2: Health Services Available in On-Reserve Communities**

+---------------+------------------------------------------------------+
| **Type of     | **Access to Health Services**                        |
| Community**   |                                                      |
+---------------+------------------------------------------------------+
| **Remote      | **Nursing Station:**                                 |
| Isolated      |                                                      |
| C             | -   Houses two or more community health nurses and   |
| ommunities:** |     other support and primary health care staff      |
|               |     organized to carry out primary health care       |
| -   no        |     services including urgent care, short-term       |
|     scheduled |     in-patient care and public/community health.     |
|     flights   |                                                      |
|               | -   Access to nurses for urgent health needs is      |
| -   minimal   |     available on a 24/7 basis.                       |
|     telephone |                                                      |
|     or radio  | -   Physician services and dental services are       |
|     services  |     provided on a visiting basis.                    |
|               |                                                      |
| -   no road   |                                                      |
|     access    |                                                      |
+---------------+------------------------------------------------------+
| **Isolated    | **Nursing Station or Health Center**                 |
| Communities** |                                                      |
|               |                                                      |
| -   Scheduled |                                                      |
|     flights   |                                                      |
|               |                                                      |
| -   good      |                                                      |
|     telephone |                                                      |
|     services  |                                                      |
|               |                                                      |
| -   no year   |                                                      |
|     round     |                                                      |
|     road      |                                                      |
|     access    |                                                      |
+---------------+------------------------------------------------------+
| **Isolated or | **Health Station**:                                  |
| semi-isolated |                                                      |
| communities** | -   Houses field unit staff consisting of community  |
|               |     health nurse(s) and other non-professional       |
|               |     health care support staff to carry out disease   |
|               |     prevention and health promotion activities in    |
|               |     the community.                                   |
|               |                                                      |
|               | -   May include primary care services for urgent     |
|               |     health needs of the community which is available |
|               |     on weekdays only and not on a 24-hour basis.     |
|               |                                                      |
|               | -   Physician services and dental services are       |
|               |     provided on a visiting basis.                    |
+---------------+------------------------------------------------------+
| **            | **Health Center:**                                   |
| Semi-isolated |                                                      |
| Communities** | -   Staffed by one or more community health nurses   |
|               |     and support personnel to carry out disease       |
| -   Road      |     prevention and health promotion activities in    |
|     access    |     the community.                                   |
|     *greater  |                                                      |
|     than 90   | ```{=html}                                           |
|     km* from  | <!-- -->                                             |
|     Physician | ```                                                  |
|     services  | -   Services for primary/urgent care are provided by |
|               |     physicians residing in the area or on a visiting |
|               |     basis.                                           |
+---------------+------------------------------------------------------+
| **Non         | **Health Center**                                    |
| Isolated      |                                                      |
| Communities** |                                                      |
|               |                                                      |
| -   Road      |                                                      |
|     access    |                                                      |
|     *less     |                                                      |
|     than 90   |                                                      |
|     km* to    |                                                      |
|     physician |                                                      |
|     services  |                                                      |
+---------------+------------------------------------------------------+

[Maternal child health services]{.underline}. According to Community
Health Program Manuals[^1], maternal child health care is comprised of
prenatal care, evacuation for birth to provincial tertiary care
facilities and postnatal care. Current prenatal and postnatal program
policy in all regions were consistent in suggesting a basic level of
health promotion and prevention services for the prenatal and postnatal
period (See Table 3: P*renatal and Postnatal Services Described in
Regional Program Manuals*). While anecdotal reports indicate that all
regions are evacuating women for birth to specialized obstetrical
services in southern Canada, no policy describing protocols or
interventions for evacuation was located.

**Table 3: Prenatal and Postnatal Services Described in Regional Program
Manuals**

+-----------+----------------------------------------------------------+
| Period    | Services/Interventions by all regions                    |
+-----------+----------------------------------------------------------+
| Prenatal  | -   Early identification of pregnancy                    |
| care      |                                                          |
|           | -   Visits to the clinic for routine check ups and       |
|           |     education(e.g. re: nutrition, alcohol, drug and      |
|           |     tobacco use)                                         |
|           |                                                          |
|           | -   Physician examination                                |
|           |                                                          |
|           | -   Identification of at risk pregnancies                |
|           |                                                          |
|           | -   Prenatal classes                                     |
|           |                                                          |
|           | -   Home visit to assess family and environment,         |
|           |     establish trust and provide information re:          |
|           |     available services                                   |
+-----------+----------------------------------------------------------+
| Birth     | -   Transport or evacuation to hospital for delivery (a  |
|           |     specific protocol for evacuation for intrapartum     |
|           |     care was not found)                                  |
+-----------+----------------------------------------------------------+
| Postnatal | -   Home visit(s) for maternal physical exam, infant     |
| Care      |     physical exam, assess attachment, post partum        |
|           |     depression and family adjustment to new baby,        |
|           |     discuss breastfeeding and nutrition, exercise, and   |
|           |     reproductive health care                             |
|           |                                                          |
|           | -   Postpartum physician exam                            |
+-----------+----------------------------------------------------------+

[Related Maternal/Child and Family Health Programs on
Reserve]{.underline}. Related programs on reserve include the Canada
Prenatal Nutrition Program, Fetal Alcohol Syndrome/Fetal Alcohol Effects
Prevention Program, the Aboriginal Head Start on Reserve, Better
Beginnings/Brighter Futures, and Canada's Action Plan for Children
programs. Responsibility for these programs is shared by Human
Development Resources Canada, Indian and Northern Affairs Canada, local
Aboriginal governments, and Health Canada. Not all communities may have
these programs on site and the size and scope of programs varies with
size of community and resources provided. Development of a comprehensive
maternal child health policy must integrate the services and supports
provided by these programs.

[What are System and Program Challenges?]{.underline}

There are a number of complex issues impacting the level and quality of
maternal child health care actually received. First, program design for
pre and post natal care varies considerably between regions. For
example, some regions have adopted an evidence-based prevention and
population health approach to service delivery and evaluation. Other
regions continue to employ policy developed in the 1980's that takes an
individual, biomedical, task oriented approach. There were a number of
strengths in each of the program manuals. For example, one region
employs a community development approach, one region included some
description of cross-cultural considerations, one region had a prenatal
screening protocol, and one region included a section on family centered
care. Integration of strengths of each of the regions to be delivered
across all regions would significantly enhance program design.

There is also a fair amount of variability in program implementation.
What services are being delivered, and by whom, at the community level
varies considerably. A further variation is in the extent and quality of
linkages with provincial or regional specialized tertiary care. (C.
MacPherson, personal communication, June 25, 2002). This variations are
due to differences in program design as well as a number of system and
implementation issues. Understaffing and lack of support result in the
bulk of staff time being spent on emergency medical treatment and crisis
intervention. The poor quality work environment leads to high rates of
staff turnover and serious shortages, especially in more remote areas. A
recent survey of FNIHB employed nurses indicates that the most remote
communities/nursing stations are disproportionately likely to have the
least educated and experienced nurses (EKOS Research Associates, August
2002). In this context, the health promotion and prevention services
that are so critical to good quality maternity care are often
compromised. In addition to recruitment and retention of qualified
staff, information management is a significant system level barrier to
effective care (Auditor General's Report, 2001).

Finally, perhaps the most significant impact on maternal child health
care in on reserve communities appears to be a result of the "evacuation
policy". By all reports, the practice of evacuation is the single most
significant barrier to quality maternity care on reserve. It is assumed,
but data not available to substantiate, that all women living in remote,
isolated and semi-isolated communities are being evacuated to provincial
tertiary care centers at 36 weeks to give birth, as per convention (no
written policy has been found at national, regional, zone or nursing
station levels of the system). Further evaluation is needed to determine
what percentage of women living in non isolated communities are being
evacuated to provincial tertiary care centers in southern Canada. For
example, there are anecdotal reports that women living in Nelson House,
a non-isolated community less than 90 kms from provincial hospital
facilities in Thompson, Manitoba are still evacuated to Winnipeg for
birth (Shirley Hiebert, personal communication, June 2002). In Duncan,
BC however, members of the Cowichan Band deliver at a provincial
hospital located 2 km from the reserve. Moreover, plans are underway for
a band-hospital liaison to increase continuity of care, and
cross-cultural understanding between hospital staff and band residents.

[What is the Impact of Medical Evacuation as the Cornerstone of Maternal
Child Health Care?]{.underline}

While the objective of this approach is to ensure medical safety,
maternal evacuation to the south at 36 weeks or earlier, to wait to
deliver, has a significant impact on the health of Aboriginal women,
families, children and communities (Blythe, 1995) **(See Table 4:
Examples of the Impact of Evacuation on Health).**

As Klein et al.(2002) conclude, "research shows us, the frequency of
small premature infants goes up, as does maternal and newborn
complications---even though the women (most but not all) have traveled
to a good place to be delivered by good people. This is due to a lack of
support from family and friends, delays in transfer, and other complex
issues" (p. 1). Little attention has been paid to the toll of the extra
stressors, the separation from their social support during this
physically and emotionally demanding period, and the impact of the
solitary experience of a highly significant and personal life event in
the company of strange people, places, food, and cultures. The physical
demands of traveling long distances at advanced stages of pregnancy, and
during the crucial first few days after the (often physically traumatic)
birth experience puts excess demands on new mothers (Klein et al., 2002)
at a time when they need to conserve energy and focus on the first tasks
of motherhood (eg. establishing breastfeeding, rest and recovery from
birth, bonding and attachment with their new infant, and adjusting
emotionally to a new self-concept and new family dynamics). Post partum
depression is more likely in women experiencing high stress and low
support during the perinatal period (Armstrong et al., 2000). The
consequences of postpartum depression on maternal, infant and family
health have been well documented (Glaser, 2000). Finally, the ability to
successfully establish breastfeeding may also be compromised due to lack
of a trusted role model or caregiver during the crucial first few hours
and days, and the excessive stress and demands imposed by evacuation.

Evacuation also negatively impacts families. It puts a strain on the
couple relationship, and precludes attachment of the infant and father
during the critical first week (Armstrong, Fraser, Dadds & Morris, 2000;
Radojevic, 1994). Absence of the primary caregiver and often inadequate
skills of the father to manage for extended periods of time (Blythe,
1995) may negatively impact siblings, (older children and teenagers)
resulting in short and long term behavioral problems.

Evacuation also deprives extended families and communities of the
opportunity to participate in the birth experience. "The alienation of
childbirth from the community is a major grievance of native people
throughout the north" (Blythe, 1995, p. 14). Moreover, loss of capacity
to manage births precipitates a negative cascade of events that
undermines the economic and social viability of a community (Klein,
2001) **(See Figure 3: Relationship between Community Birthing Capacity
and Sustainability).**

[Who is the Target Population and Where do They Live?]{.underline}

The Aboriginal population is a young and rapidly growing population,
relative to people living in the rest of Canada. It's growth rate (3%)
is double that of the general population. Figure 3 illustrates the
geographical distribution of the total Aboriginal population. This
population growth is exerting "significant pressure on the present
infrastructure for delivering services." (Auditor General's Report,
2001). The on reserve Aboriginal population is roughly 60% of the total
Aboriginal population, and is distributed in 612 communities of varying
sizes in urban, suburban, rural and remote areas of Canada (See Figure
4). Population distribution by community type and age is shown in
**Table 5: Number and Percentage of Status and Non-Status Population
Living on Reserve by Type of Community 2002-2003.** Population figures
for the non-isolated and semi-isolated communities are not deemed
accurate, estimating a net under calculation of the on reserve
population. This would make the population living in remote and isolated
communities an even smaller proportion of the total population. This is
significant given the generalized application of the evacuation
"policy".

Table 5 and the map in Figure 4 illustrate several facts relevant to the
evacuation practice. First the percentage of children less than one year
of age in remote and isolated communities is 28.4%, which would roughly
indicate the birth rate for the previous year. If it is assumed that
degree of isolation is one of the main factors determining the need for
evacuation for birth, then over 70% of the population may live in areas
where community birthing services could be developed. Second, even in
areas where community birth services are not feasible, evacuation to a
regional rather than specialized provincial tertiary care center may be
feasible. Analysis of demographic and population distribution
information, with population health status data (eg. risk status) would
be needed to estimate the proportion of women eligible for community
based birth.

**Table 4: Number and Percentage of Status and Non-Status Population**

**Living on Reserve by Type of Community 2002-2003**

  --------------------- ------------- ---------- -------------- ------------- --------- -------------
  Community Type        **\<1year**              **Total                                
                                                 Population**                           

                        \# %                                    \#                      \%

  Remote Isolated       221           2.4%       6919                         1.7       

  Isolated              2431          26.0%      101815                       24.3      

  Semi Isolated         1096          11.7%      42310                        10        

  NonIsolated           5591          59.9%      266760                       64        

  **Total**             **9339**      **100%**   **417804**                   **100**   
  --------------------- ------------- ---------- -------------- ------------- --------- -------------

> [^2] non-isolated and semi-isolated numbers reflect only those persons
> who 'access' those facilities as the population have alternate (ie
> provincial systems) equally available to them.
>
> [Aboriginal Health Status Issues Impacting on Maternal Child Health
> Care]{.underline}

The most recent data on Aboriginal health and health care utilization
demonstrates the consequences of working downstream (Martens et al.,
2002). A 'downstream' approach intervenes *after* health problems have
emerged and have progressed to the stage that activities of daily living
are affected and people seek expensive medical intervention.
Alternatively, an 'upstream approach' aims at prevention and development
of skills and capacity for successful living.

**Table 6** highlights several health indicators relevant to
maternal-child health derived from a number of sources as indicated by
footnotes in the table. The overall poor health status of Aboriginal
people in Canada illustrate the long term health impact of 'down stream'
health policy approaches. For example, Martens et al. (2002) found that
Aboriginal people in Manitoba have twice the premature mortality rate
compared with the mainstream population (6.6 vs. 3.3/1000), with some
areas even as high as 9.3/1000. Breastfeeding initiation rates averaged
57.1% in Manitoban First Nations populations, versus 80.5% in the
non-Aboriginal population. Hospitalization separation rates are double
for Aboriginal people: 348 vs. 156 days?/1000 population/year.
Similarly, contact with physicians is higher with an average of 5.8
visits/person/year for Manitoban Aboriginal people vs. 4.7
visits/person/year for the mainstream population. Martens et al. (2002)
concluded that poorer health is not due to lack of medical services, and
that a stronger emphasis on prevention is needed. For example,
increasing immunization and breastfeeding rates were identified as
priority areas for programming.

There are a number of health and social characteristics of the on
reserve Aboriginal population that are significant to maternal child
health care delivery and outcomes. Lower rates of educational
attainments, elevated rates of alcohol abuse and dependency, smoking and
environmental tobacco smoke, domestic violence, barriers to food
security and adequate nutrition, and the prevalence of Type II Diabetes
have all been demonstrated to be associated with poorer maternal child
health outcomes. Table X: Compares rates of health indicators relevant
to maternal-child health in the Aboriginal population and the rest of
the Canadian population. Addressing the considerable risks that these
issues pose for pregnant women and their babies must be factored into
developing a comprehensive maternal child health care policy.

The implications derived from this review are that delivery of maternal
child health care is significantly different in Aboriginal versus
non-Aboriginal populations, and in northern verses southern Aboriginal
communities, due to variability in geography, population distribution,
key maternal child health status indicators, and cultures. The reality
of the health status, cultural and contextual differences requires that
maternal child health care policy be very flexible and responsive to the
unique situation, history, culture, strengths and readiness of each
community.

In sum, a new design for maternal child health care appears to be
required to fulfill the principles of the Canada Health Act (1984) for
on-reserve communities (Graves, Beauchamp & Herle, 1998) and the intent
of the Indian Act, 1979. As it stands, current "policy" appears to focus
on evacuation of women to tertiary care centers. Health promotion and
prevention appear to be receiving less emphasis and programming is not
consistently applied with poor implementation due to system constraints,
health human resource shortages and turnover, and lack of attention to
policy and program development and support. Related programs are poorly
integrated and there is no overarching approach to standardized maternal
child services. The poorer health status of Aboriginal people may in
part be attributed to the considerable lag in the quality and support
for implementation of evidence-based maternal/child health policy and
programs. Serious challenges are also imposed by sparse population
distribution and geographical isolation, the consequences of European
colonization and centuries of political and socio-cultural struggle.

**Values: A Vision and Goals for Maternal Child Health Care on Reserve**

Aboriginal values, the value placed on evidence-based health care in
Canada, and the values and evidence guiding national and international
standards for quality maternal child health care must form the basis for
a vision and goals for maternal child health care in Aboriginal
communities.

[Aboriginal Values]{.underline}

Aboriginal values about health and health care were elicited through
consultation with stakeholders, key policy documents (Government of
Canada, ; Royal Commission on Aboriginal People, 1996; Assembly of First
Nations, 2001), and position statements (Svenson and Lafontaine, 1999;
SOGC 2000). Stakeholders were consulted on values and practices of
Aboriginal women, families and communities through informal dialogue
with key informants and a focus group discussion **(See Appendix A:
Stakeholder Consultations)**. These consultations also helped to
identify relevant literature and policy documents, as well as other key
informants.

For example, the Royal Commission on Aboriginal People (1996)
recommended that:

*new Aboriginal health and healing systems should embody four essential
characteristics:*

-   *Pursuit of equity in access to health and healing services and in
    health status outcomes*

-   *Holism in approaches to problems and their treatment and
    prevention*

-   *Aboriginal authority over health systems and,where feasible,
    community control over services, and*

-   *Diversity in design of systems and services to accommodate
    differences in cultures and community realities* (Volume 3, p.
    223-224) (cited in FNIRHS, 1999, p.225-6).

    Stakeholder focus group participants suggested the following
    'guiding principles' for development of a new maternity care policy:
    safe and appropriate care, holistic, 'upstream' approach, cultural
    relevance/safety, capacity or asset oriented, multidisciplinary and
    community determined.

    [Evidence Linking Maternal Child Care and Long Term Health
    Status]{.underline}

    There is a substantial and growing body of evidence to explain how
    the quality of the physical, social and emotional environment during
    pregnancy, birth and the first weeks postpartum are critical to both
    short term and long term health and quality of life. Two key
    examples of the powerful influence of perinatal development on life
    long health include the evidence on early brain development, and
    infant attachment. This evidence supports Aboriginal values
    advocating for an 'upstream' approach to health policy.

[Early brain development]{.underline}. The impetus for enhancing early
childhood development as a key strategy to improve population health is
based largely on research on early brain development (Doherty, 1998;
Hertzmann, 2000), and longitudinal measures of the impact of early
intervention (Durlak and Wells, 1997; Guralnick, 1998) **(See Figure 5:
Pathway of Effects between Perinatal Development and Life Long
Health)**. The actual cellular structure that determines capacity for
life long health and productivity is laid down during the
neurobiological development of the fetus and young infant. The quality
of the physical, social and emotional environment during this very early
period profoundly impacts cellular development and therefore an
individual's potential in life. Negative influences in the physical,
social and emotional environment can severely restrict an individual's
intellectual, social and physical capacity for the rest of his/her life.
Longitudinal research measuring the impact of interventions to enhance
the quality of the environment clearly and consistently demonstrates
payoffs for both individuals and society (Fuligni and Brooks-Gunn, 2000;
McCain & Mustard, 1999; Peters, Arnold, Petrunka, Angus, Brophy, Burke,
Cameron, Evers, Herry, Levesque, Pancer, Roberts-Fiati, Towson, &
Warren, 2000). For example, it is postulated that more than \$7 is saved
for every dollar spent to enhance early development (Hertzmann, 2000).
Furthermore, investments in provider initiated comprehensive services
for moderate to high risk clients has been demonstrated to be recovered
within one year through decreases in service utilization (Browne, Byrne,
Roberts, Gafni, & Jamieson, 2000).

[Attachment]{.underline}. "Maternal-fetal attachment represents the
earliest and most basic form of human intimacy" (Condon & Corkindale,
1997, p. 359), and sets the stage for an individual's ability to form
intimate relationships throughout life. The quality of maternal-fetal
attachment during pregnancy and maternal-infant attachment after birth
has been shown to have significant impact on the infant development
(Condon & Corkindale, 1997). Attachment also influences the mental
health and level of functioning of mothers and families (Armstrong,
Fraser, Dadds & Morris, 2000). Research is also exploring similar
relationships between father-infant attachment, the effectiveness of
family functioning during infancy, and the quality of infant development
(Radojevic, 1994). Further, evidence suggests a significant relationship
between maternal psycho-social health, the quality of maternal-infant
attachment, and mental health problems during childhood later life
(Barlow & Coren, 2002). Similar to the case of early neurobiological
development, social and emotional development is also influenced by the
quality and supportiveness of the family and social environment
(Webster, Flenady & Woodgate, 2002).

In sum, the evidence on the influence of maternal child health on life
long health provides a strong rationale for investments during this
period, as well as direction for intervention. Supporting development of
strong neurobiological, emotional, and social foundation for human
development results in economic and quality of life payoffs for
individuals, families and communities, and also enhances the value for
dollar of societal investments further along the pathway of human
development (eg. school). Interventions must be directed at increasing
the quality and supportiveness of the physical, social and emotional
environment influencing human development at level of individual women,
families and communities.

[Standards of Maternal Child Health Care]{.underline}

Current standards for maternal child health care were synthesized from
national and international guidelines. These evidence-based guidelines
for programs and interventions consistently demonstrate that quality
maternal child health care is, first and foremost, focused on health
promotion interventions beginning in the preconception period and
continuing through until early infancy. The secondary emphasis is placed
on early detection of problems and provision of skilled, easily
accessible primary medical care. Capacity for emergency response to
obstetrical and neonatal complications is a third critical component of
quality maternal child health care. **Figure 6: Emphases in High Quality
Maternal Child Health Care** depicts the relative emphases of each of
these 3 components. The largest component, comprised largely of an
effective prevention and health promotion program of interventions,
mitigates against the need for early detection of problems and primary
medical care. In turn, well executed early detection and primary medical
intervention reduces the incidence of cases needing emergency care.  
 International standards for emergency medical obstetrical care (EMOC)
(UNICEF, 1999) recommend that for every 500,000 people there should be
four facilities offering Basic EMOC and one facility offering
Comprehensive EMOC.  The difference between Basic EMOC and Comprehensive
EMOC is the functions of giving blood and performing surgery.
Differentiation of level of facilities likely indicate that evacuation
to specialized obstetrical tertiary care facilities located along the
49^th^ parallel in southern Canada, may be required for high risk women,
but may not be universally indicated for women at moderate risk.

The proportionate emphases in Figure 6 is evident in the preponderance
of prevention and health promotion interventions during the
preconception, preconception, prenatal, birth and postnatal period,
recommended by national (Health Canada, 2000; New Zealand Health Funding
Authority, 2000) and international (UNICEF, 1999) maternity care
guidelines. Preconception interventions include healthy sexuality
education during youth and adolescence, family planning/contraception,
and adequate nutrition, including the need for dietary folic acid.
Prenatal services include risk screening protocols, folic acid
supplementation, abuse screening and intervention, alcohol and drug
prevention and treatment, interventions to reduce maternal smoking and
fetal exposure to environmental tobacco smoke, and interventions to
ensure adequate social support. Birth care at minimum must ensure
cultural and medical safety, and supportive, holistic woman/family
centered support and intervention. Postnatal support and intervention
includes holistic mother-infant assessment and intervention, information
and counseling on infant nutrition and care such as breastfeeding and
the importance of rest, immunization, family planning and infant
attachment. Provisions for grief support (in the event of fetal loss or
congenital conditions), transportation, effective linkage and
integration, and program monitoring and evaluation are also essential
components of maternity care.

[Synthesis of Values for New Maternal Health Policy on
Reserve]{.underline}

Synthesis of Aboriginal values, evidence on perinatal health and
standards for quality maternal child health care identifies the
following key values/principles for health care: ethical, culturally
safe, community determined/designed, equitable, and multidisciplinary.

[Ethical Health Care]{.underline}. Regardless of the effectiveness of
care provided, there will always be some women who are at medium or high
risk while pregnant (UNICEF, 1999). While the realities of geographical
isolation and sparse population present challenges to providing
services, limiting the quality and extent of care solely based on
geography is inappropriate. Effective maternity care is a human right
and part of ethical health care (Merali, 2001). Safe and appropriate
care must be informed by principles of human rights for ethical care, as
well as the best evidence of effectiveness of interventions **\[See
Table 7: Principles of Human Rights for Ethical Health Care**\]. Policy
makers and health professionals must recognize the social justice issues
embedded within the assumptions and realities of providing maternity
services to women and families on reserve. Furthermore, assumptions
about what constitutes 'quality care' (eg. high tech tertiary care
services) in the context of maternal child health may challenge ideas
that quality must by necessity be limited by geography.

+-----------------------------------------------------------------------+
| **Table 7: Principles of Human Rights for Ethical Health Care         |
| (Merali, 2001)**                                                      |
+-----------------------------------------------------------------------+
| -   The right to accurate information                                 |
|                                                                       |
| -   The right to free and informed decision-making                    |
|                                                                       |
| -   The right to privacy                                              |
|                                                                       |
| -   The right to confidentiality                                      |
|                                                                       |
| -   The right to choice                                               |
|                                                                       |
| -   The right to dignity                                              |
|                                                                       |
| -   The right to access, regardless of sex, sexual orientation, race, |
|     disability, marital status, age, socioeconomic class,             |
|     location...etc                                                    |
|                                                                       |
| -   The right to safety                                               |
|                                                                       |
| -   The right to express an opinion                                   |
|                                                                       |
| -   The right to participation                                        |
|                                                                       |
| > Based on:                                                           |
| >                                                                     |
| > Cook, R. & Dickens, J. (1998). [Considerations for formulating      |
| > reproductive health laws]{.underline}. Geneva: WHO.                 |
| >                                                                     |
| > International Planned Parenthood Federation (IPPF). (1997). [IPPF   |
| > charter on sexual and reproductive rights and rights of the         |
| > client]{.underline}. London: IPPF.                                  |
| >                                                                     |
| > WHO/UNICEF/UNFPA. [Women friendly health services: Experience in    |
| > maternal care]{.underline}. Mexico City workshop. January 26-28,    |
| > 1999.                                                               |
+-----------------------------------------------------------------------+

[Culturally Safe Health Care]{.underline}. "Cultural competence goes
beyond cultural sensitivity to include "care that is provided within the
cultural context of clients" (Affonso, Mayberry, Inaba, Robinson and
Matsuna, 1995, p.35). Cultural safety goes beyond this definition to
include analysis of power imbalances that may compromise a client's real
or perceived ability to receive effective care. The Nursing Council of
New Zealand (1992) adopted the definition of cultural safety as:

*The effective nursing of a person/family from another culture by a
nurse who has undertaken a process of reflection on own cultural
identity and recognizes the impact of the nurse\'s culture on own
nursing practice. Unsafe cultural practice is any action which
diminishes, demeans or disempowers the cultural identity and wellbeing
of an individual.* *Cultural safety... gives people the power to comment
on care leading to reinforcement of positive experiences. It also
enables them to be involved in changes in any service experienced as
negative.*(cited in University of Southern Queensland Master of
Midwifery Program, 2002, p.1)

Elaborations of culturally safe care echo the principles of ethical
health care outlined in Table 1, but add a cultural dimension to the
analysis of power differences that may interfere with these rights.
There are a couple of reasons why greater attention to cultural safety
is of particular importance in on-reserve Aboriginal communities. While
initiatives are underway to recruit and educate more Aboriginal health
care professionals, the majority of health care providers on reserve in
Canada are still non-Aboriginal. Second, enhancing the cultural safety
of health care will enhance both access to and the effectiveness of
care. Further, integration of traditional knowledge and practices will
be facililated in a culturally safe health care environment. Culturally
safe practice and integration of traditional knowledge and practices
will demonstrate respect and affirm Aboriginal peoples' cultural
identity. This affirmation can contribute to healing of Aboriginal
people and communities (Svenson & Lafontaine, 1999), and build a new
relationship between Aboriginal non-Aboriginal people.

[Community determined/designed]{.underline}. A change to community
control over health services, as called for by the *Royal Commission on
Aboriginal People*, is an explicit demand for a change in the power
relations. In particular, community control over their birthing is
essential to Aboriginal healing and cultural integrity (O'Neill, 1990).
Pregnancy, birth and childcare have traditionally been a "woman
controlled and managed" part of Aboriginal cultures (Elder Benedict,
personal communication, June 20/02; Blythe, 1995). "Pressure for a more
community responsive system of obstetric care is part of a wider demand
for more community control and a drive to preserve traditional values in
relation to pregnancy and childbirth" (Blythe, 1995, 15). Grassroots
movements to reassert control over pregnancy and birth have demonstrated
success in developing community controlled models of maternity care that
integrate traditional methods with conventional western medical
approaches (Calm Wind and Terry, 1993; see also Innulitsivik Maternity
and Iewirokowas Program descriptions below).

[Equitable Health Care.]{.underline} An attitude of investment in
evidence-based upstream interventions to transform the short and long
term health status of Aboriginal people is necessary to achieve equity
in health in Canada. Equity in health is "the absence of systematic
\[and potentially remediable\] differences in one or more aspects of
health status across socially, demographically, or geographically
defined populations or population subgroups" (Starfield, 2001, cited in
Macinko & Starfield, 2002, p. 3). Horizontal equity means that there are
no differences in access to health services where health needs are
equal. Vertical equity involves the notion of distributive justice, and
requires that additional health services be provided to reduce
disparities in health status between groups. Distributive justice is
achieved through health care policies aimed at distributing health
*outcomes* equally across individuals and groups in society (Mooney and
Jan, 1997). Thus considerations of horizontal equity would seek to
achieve equity in access despite differences in geography for on reserve
communities in rural and remote areas. Vertical equity would support
additional spending to address the disparities in the health needs of
many Aboriginal women, in order that maternity care outcomes begin to
approach rates similar to the mainstream Canadian population.

Given goals of both Aboriginal people (Assembly of First Nations, 2002)
and the federal government (Government of Canada, 1998; 1994) regarding
Aboriginal health, short term illness-oriented economic analyses of
alternatives to maternity care are inappropriate. Methods of cost
effectiveness analysis must encompass much more than short term health
services costs, or immediate medical benefits (Browne, Byrne, Roberts,
Gafni and Jamieson, 2000). The "96/4" reality of costs of health service
provision (Forget, Deber and Roos, 2002) must be factored into any
determination of economic efficiency. For example, analysis of hospital
and physician costs in Manitoba showed that the sickest 50% of the
population accounted for 96% of the costs, while costs incurred by the
healthiest 50% totaled 4%. Costs of providing care to populations known
to have higher morbidity and mortality rates, such as Aboriginal people
in Canada, cannot be evaluated against costs for provision of the same
services in the mainstream Canadian population.

[Multidisciplinary]{.underline} . The review of the literature by Klein
et al (2002) identified the "synergy between general and specialist
physicians, nursing and regulated midwifery. Each profession is key to
an adequate and safe maternity service". An effective complementary mix
of providers is especially important in northern communities that will
continue to be the hardest hit by shortages of skilled health care
professionals. Role modeling of a more diverse mix of health
professional roles such as midwife, doula, nurse, nurse practitioner,
community health representative and physician will also be a positive
step toward building a cadre of Aboriginal health professionals, and the
long term goal of self--reliance.

> **Information: Synthesis of Evidence for Effective Intervention**

Scientific and experiential evidence for models and interventions were
synthesized based on the values and standards identified, and the
contextual and population needs and issue. The evidence on interventions
and approaches was scrutinized for effectiveness in meeting these needs
regardless of risk status or geographical location. Specifically, how
effective was/would the intervention be in the on reserve culture and
context: is there information on delivery of appropriate dose (how
much), intensity (how often) and duration (for how long) of
intervention. A tabular approach was used to synthesize key messages and
recommendations from the scientific evidence on intervention
effectiveness. **(See Appendix B: Synthesis of Evidence for Maternal
Child Health Care Intervention).** In summary, the evidence suggests
that effective maternal child health programs emphasize: community
control or involvement, cultural safety or appropriateness, development
of a trusting relationship with a primary care giver, home visiting as a
cornerstone of a multiple intervention approach, no specific discipline
as optimal, and implementation with enough support to preserve program
integrity and enable effective evaluation.

[Community Control or Involvement]{.underline}

There was strong consensus that community control was essential to both
effective programs and effective individual care. Evidence consistently
recommended that participants be involved in tailoring the dose,
intensity and duration of their care. It was also consistently
recommended that communities be involved in design, implementation and
evaluation of programs. Community involvement in program and client
involvement in tailoring care was also described as empowerment/advocacy
approaches to intervention. In addition, community involvement in
development of policy, structure, content, training and evaluation was
deemed to allow optimal use of stakeholder knowledge and skills.

[Cultural Safety or Appropriateness]{.underline}

Involvement from informal leaders of the most vulnerable groups in a
community were more likely to be culturally safe. Involvement of local
women also enhanced program recruitment, retention and intervention
effectiveness. Models that emphasized both culturally appropriate and
community driven design and implementation approaches were more
effective at achieving early recruitment during the prenatal period.
Early recruitment and cultural safety were also necessary to accurately
assess and begin intervention for risk factors.

[Development of a Trusting Relationship with a Primary Care
Giver]{.underline}

Development of a trusting relationship with a primary caregiver during
pregnancy was deemed essential to both accurate assessment/screening and
effective intervention. Effectiveness and sensitivity of prenatal risk
factor screening tools (eg. for abuse, alcohol or tobacco use)
administered other than in the context of a trusting relationship were
deemed unreliable. Moreover, postnatal interventions were more effective
if delivered in the context of a trusting relationship that had been
developed during the pregnancy. Team based approaches (e.g. disruption
of women-caregiver continuity, but maintenance of continuity of
information about the woman's care) were effective in low risk
populations. Interventions delivered through a trusting relationship
developed with one primary caregiver that remained continuous throughout
the preconception to postpartum period were more effective with moderate
and high risk women/pregnancies.

[Home Visiting /Multiple Intervention Approach]{.underline}

Evidence suggests that home visiting as a cornerstone of a comprehensive
maternal child health program can: improve parenting skills and the
quality of the home environment; improve intellectual development of
young children, especially among those with low birth weight; decrease
incidence of unintentional injury to children, improve detection and
management of postpartum depression, enhance quality of social support
to mothers, and improve rates of breastfeeding. Evidence from economic
evaluation of home visiting to parents and young children indicates a
net cost savings. While there was strong consensus that home visiting is
an essential component of effective support and intervention programs,
there were several qualifiers regarding its application. First, the
efficacy of home visiting varied with characteristics of the population.
For example, high dose, high intensity home visiting of prolonged
duration was consistently found to be both effective, and cost effective
in high risk populations. However, there was limited utility of high
dose, high intensity home visiting programs of long duration in low risk
populations. Second, home visiting was deemed most effective as one part
of a multiple intervention program that included components such as
community level breastfeeding education and advocacy, hospital and
clinic based support and interventions, nutrition support and education,
and referral to other community resources. Overall, home visiting was
recommended as a universally implemented strategy that could be tailored
in consultation with individual clients regarding dose, intensity and
duration. It was consistently implemented in the context of a
multidisciplinary team with professional supervision and support.

[Disciplinary Issues]{.underline}

Designation of a specific discipline as most effective as the primary
caregiver was not supported by the evidence. Generally it was the model
of care, rather than the discipline of the care provider that determined
both satisfaction with and effectiveness of care. Models that were
woman-centered, promoted development of a trusting relationship,
included a strong emphasis on prevention and holistic care were more
effective. For example, midwifery care achieved equal or better maternal
and neonatal outcomes, and less complications of birth than conventional
obstetrician led care in low risk populations. Public health nursing led
interventions were also found to be effective across a number of low,
moderate and high risk populations, when tailored to individual client
needs and circumstances. Lay care providers, carefully selected,
trained, and supported as part of a multi-disciplinary team were
consistently recommended as primary caregivers for members of higher
risk, socially disadvantaged or ethnic minority communities. Maturity,
flexibility, culturally sensitive communication skills, a sense of
compassion and interest in the community are examples of characteristics
found to be important in selection of effective lay care providers.

[Adequate Support for Implementation and Evaluation]{.underline}

Implementation of a program as it was designed, or 'program integrity'
must be preserved for programs to be effective. Regardless of model or
discipline, achieving program integrity requires sufficient time,
resources, personnel, technical expertise, careful recruitment of team
members, appropriate orientation and ongoing training, and adequate
leadership and support. A number of studies also recommended team
building strategies as important prerequisites for successful
implementation. Examples of recommended team building strategies include
participatory dialogue around program design and development, common
space to promote understanding of disciplinary expertise and
orientation, regular team meetings, and joint continuing education.
Moreover, several studies emphasized adequate training and continuing
education as essential to safe practice.

The evidence on maternal child health interventions strongly recommends
that interventions implemented in populations other than that of the
study must be rigorously evaluated. Process and outcome evaluation is
needed. Examples of outcome indicators for quality of care included
caesarean rates and other complications of birth, maternal satisfaction
with care, rates of early recruitment and retention of the target
population, and breastfeeding initiation and duration rates.
Recommendations for program monitoring and formative evaluation of
process suggested indicators such as retention of program staff, and
client attendance at interventions. Tracking demographic characteristics
and individual care planning of dose, intensity and duration of specific
program components such as lay home visiting was also recommended.

[Experiential Evidence: Alternative Models of Maternity
Care]{.underline}

Several models of maternity care from Canadian Aboriginal, mainstream,
and international contexts were scanned for potential to accommodate the
geographical and population challenges of delivering maternal child
health care to on reserve Aboriginal communities. The rationale for
consideration of each program, and its fit with the values and evidence
for maternal child health care on reserve is briefly described.
Conclusions regarding which of these programs warrants further
exploration for potential inclusion as part of a new policy are
provided. It must be noted that these models have not been evaluated
using experimental or quasi experimental designs to determine
effectiveness, but they are included here for their potential
contribution to policy innovation.

[System level initiatives /models]{.underline}. There are several
examples of comprehensive, prevention oriented programs that have been
developed specifically for addressing the maternal child health and
cultural safety needs of Aboriginal and other ethnic minority
communities. The British Columbia Pregnancy Outreach Projects (POP) is
similar to 'Healthy Babies/Healthy Children' programs in other
provinces. The BC 'POP' program aims to recruit early in pregnancy, and
supports women and their families well into the post partum period. It
uses a multidisciplinary team (nurses, nutritionist, alcohol and drug
counsellors and lay support workers) and a community development
approach. The program uses a multiple intervention approach, including
home visiting by lay support workers. It specifically targets 3 risk
factors relevant to Aboriginal communities: nutrition, social support,
and substance use (both tobacco and alcohol). Also, the policy
implementation approach is worth further exploration. The BC program
started with one pilot community, and then rolled the program out to a
further 6 communities based on community readiness and need. Both
qualitative and quantitative methods are used in program evaluation. The
third phase enabled a much larger number of communities to be included.
Community readiness and preparation for the program was enhanced by
dissemination of the experience and successes of communities in the
initial two phases of the program.

The American College of Obstetricians and Gynecologists' Fetal Infant
Mortality Review Program (FIMR) is a community-based action oriented
continuous quality improvement program. It begins with quantitative
population based data, and uses community-based, action oriented
strategies to identify positive and negative social, economic, cultural,
safety and health factors associated with overall fetal and infant
mortality, and patterns of mortality across communities and population
groups. FIMR works with community to plan, implement and evaluate
targeted and culturally competent interventions and policies to address
negative factors and improve services systems and community resources
(ACOG, 2002). Community coalition/partnership building, including the
voices and experiences of local families, and designing outcome
interventions based on decisions of the whole community are 3 components
of the program that are particular valuable to reducing disparities
between communities and groups. This program merits further
consideration for Canada's on reserve maternal child health policy
because it may address weaknesses in the current health information
system. It could be a viable interim step to establish effective linkage
between accurate, reliable system level population health information,
and local level program implementation and effectiveness. It would also
be an effective community education tool, and build capacity for
community control of maternal child health.

CIET's [^3] sentinel community surveillance model (Andersson, 1995)
would dovetail nicely with FIMR when planning an evidence-based approach
that deals with information system weaknesses, while also promoting
public education of maternal child health issues and building community
capacity for managing its health care. This surveillance model "uses a
synthesis of methods that includes household questionnaires, reviews of
institutional data, key informant interviews, focus group discussion,
geographic information systems (GIS) and low-cost environmental
measurement. Using these methods, a rich mix of quantitative and
qualitative data can be analyzed with respect to each sentinel community
for its own planning needs. The community data, properly weighted for
population differences, can then be aggregated and contrasted for
planning and communication at the district, regional and national
levels" (CIET, 2002, p.1). For example, a calendar of maternal child
health issues could be developed (e.g. January is low birth weight
month, February is fetal alcohol syndrome/fetal alcohol effects month,
March is neural tube defect month, April is environmental tobacco smoke
month and so on) and used to implement a sentinel community surveillance
system.

The New Zealand Lead Maternity Caregiver model operationalizes a women's
right to choice, and is based on a holistic woman-centered approach (New
Zealand Health Funding Authority, 2000). This model includes regional
access to secondary and tertiary maternity services, as well as access
to provincial specialist neonatal and obstetrical care services. Other
components include pregnancy and parenting education and support, high
risk maternity support services, home help and mothercraft inpatient
services, and consumer information/public education. The LMC model is
worth consideration as it explicitly incorporates access to both
regional and provincial level tertiary level maternity services.
Exploration of home help and public education components of the program
are also warranted.

The Pan American Health Organization (PAHO) initiated a similar program.
The PAHO 'focus centers' operate on the principle that the best
qualified professional to manage complications is available in the
centre (e.g. obstetrician, gynecologist, medical doctors, midwife).
Concentric circles of services extend out to more remote, less populated
centers to make the best use of professional expertise,
technology/consulting, and referrals. They have found this approach
effective in producing the best all round outcomes (social,
psychological, physical, mental and spiritual for mother, infant and
family), in sparsely populated areas.

[Midwifery and Aboriginal Midwifery Models.]{.underline} There are two
programs currently operating in Canada that are integrating Aboriginal
midwifery and traditional practices with mainstream western medicine.
The Iewirokwas Program operates on the Akwasasne Reserve located in
southeastern Ontario, southwestern Quebec and northern New York State.
"The program aims to restore to Mohawk women their power, dignity and
self-efficacy in the childbearing years and at birth in all settings".
It is developing a community and culture based midwifery education
program, and a practical woman-centered family birth program. It offers
information and support to empower women and their families during the
prenatal period to inform them of their rights, traditional Mohawk
birthing rites, and to make good birthing decisions. It educates local
maternity nurses, obstetricians and hospital staff about traditional
Mohawk birthing practices to enable them to better support Mohawk women.
The program is also involved in political action and policy change to
obtain an exemption for Aboriginal midwives in Quebec's midwifery law
(Iewirokwas, 2002).

The Innulitsivik Maternity, located in Povungnituk, came about through
collaboration between local well seasoned health care professionals and
the Native Women's Association. It aims to "put the responsibility for
organization and provision of women's health care services into the
hands of the Inuit women" (Stonier, 1990, cited in Blythe, 1995, p. 15).
Inuit women are recruited from local communities and trained to work in
collaboration with professional midwives. The Inuit midwives provide
most of the basic care under supervision by the professional midwives.
Traditional practices are interwoven with conventional midwifery care.
The service is delivered in the language of Inuktituk. The majority of
women give birth at the Maternity, with high risk pregnancies sent south
to deliver (Blythe, 1995).

[Birthing Centers]{.underline}. A midwifery operated birthing centre was
initiated in Rankin Inlet as part of a study to identify whether
community based low risk birthing was safe, cost-effective and
satisfying for Inuit women in a community in the Northwest Territories
(Chamberlain, Moyer, Nimrod, Smith, and England (1997). Two
nurse-midwives provided care to all pregnant and postpartum women and
delivered those who were designated as \'low risk\' for maternity
complications. The experience of the Rankin Inlet birthing center
demonstrates that academic-practice collaborative initiatives can be
effective at supporting a change in policy. Further strong involvement
and leadership from local people, and women in particular, has been
suggested as key ingredient for for sustainability and growth that must
be incorporated into such initiatives (S. Tedford, personal
communication, August 2002). Findings from the Rankin inlet project also
support the integration of on and off reserve populations to increase
sustainability of community based birthing in sparsely populated areas.

**Limitations, Recommendations and Next Steps**

What are the most serious limitations of the environment, the evidence
and the process used to develop this paper? How can the vision and goals
for maternal child health care best be achieved, given the
characteristics of the population and the environment and in light of
the evidence? Suggestions for the next steps in the process of
developing a new policy for maternal child health on reserve are
offered.

[Limitations]{.underline}

-   Time: this paper was written in the context of a 3 month policy
    practicum. This limited the extent to which gray literature (eg. on
    local initiatives such as Povungnituk, Iewirokas program and
    others), and system information was retrieved and included.

-   Scope: the broad scope of this discussion document precluded
    systematic review of the evidence. However, systematic reviews of a
    large variety of subtopics were retrieved and incorporated into the
    synthesis of the evidence. Development of specific interventions
    ideally would be informed by a systematic review of the available
    evidence.

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-   Evidence: the majority of the evidence synthesized has limited
    generalizability to the specific culture and context of on reserve
    communities. Most studies were undertaken with nonAboriginal
    populations. The studies on breastfeeding by Martens et al are
    notable exceptions.

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-   Consultation: The short time available and the early stage of the
    policy development process precluded consultation with Aboriginal
    women and direct care providers currently working in rural and
    remote Aboriginal communities. Their perspective is paramount to
    developing a responsive, feasible maternity care program.

-   Data: Lack of data on current policy outcomes. Despite the concerted
    efforts of many people, retrieval of data on the population and
    current service delivery was very poor. This appears to be due in
    part to poor availability of data: there is no systematic collection
    of information regarding many aspects of maternal child health care
    delivery. It also seems to be due in part to lack of support and
    time for field staff to complete information management
    requirements.

    [Recommendations]{.underline}

    Recommendations flowing from the synthesis of information, values
    and structures are organized by implications for program design,
    program implementation and program evaluation. Recommendations for
    research were also extracted from the synthesis.

    [Program Design:]{.underline}

1.  Establish a system of comprehensive maternal child health promotion,
    screening and prevention interventions and supports based on
    evidence, including interventions from preconception through the
    prenatal and postnatal period. A quick first step toward development
    of a cutting edge policy could be to pull together existing
    guidelines in each of the regions, extract the strengths, update it
    with current evidence, critique and amend it for cultural safety to
    develop a current template accessible to all. The information
    management, health human resource and support needs would also need
    to be developed.

2.  Make evacuation a single, well planned out and supported component
    of a comprehensive and continuous maternity care service. This may
    include:

    a.  Determining the proportion of women at high, medium and low risk
        for birth and neonatal complications.

    b.  Assess the capacity of more proximal provincial facilities to
        accommodate moderate risk women and families for their
        intrapartum care needs.

    c.  Develop protocols for evacuation of women to both regional and
        central provincial facilities to support healthy transition
        through birth and the first weeks post partum.

3.  Inculcate culturally safe, ethical health care as a bottom
    line/non-negotiable for maternity care. This will require that
    health care providers receive significant training and support to
    develop competencies for culturally safe care. It also means that
    adequate resources are needed to support staff on the front lines to
    work in a culturally safe paradigm of care.

4.  Work on a community by community basis to repatriate birth back to
    on-reserve Aboriginal communities. Community readiness for delivery
    of low risk women in isolated and semi-isolated communities must be
    explored with key stakeholders in the communities themselves.
    Provide funding to support on reserve deliveries for low risk
    mothers and infants on a gradual implementation basis.

5.  Establish Women's Neighborhood Watch program in each community to
    ensure early recruitment into pre-natal care (Affonso et al.).

6.  Establish home visiting by lay workers in each community within the
    structure and professional supports of a comprehensive maternal
    child health program.

7.  Ensure that each community health center has a dedicated public
    health nurse who is responsible and accountable for the maternal
    child health program and its various component parts, integration of
    other team members and inter-jurisdictional communication and
    collaboration to ensure continuity of care (see Affonso et al., ).

8.  Community education is needed to facilitate cultural shift;
    communities have been socialized for decades to believe that flying
    out is the only option; the landscape has changed considerably and
    there are other viable options out there can produce better
    pregnancy and birth experiences and population health outcomes
    within the current and future health human resource, service
    delivery and economic context.

[Program Implementation]{.underline}

Several recommendations for program implementation are suggested by the
analysis of structures, values and information for maternal child health
care on reserve.

1.  Develop information management capacity. Certainly the
    maxim[,]{.underline} "what is counted is what counts" is apropos to
    health care delivery on reserve. Specific suggestions include:

    a.  For the short and medium term, implement a surveillance action
        system similar to that described by ACOG FIMR and CIET's
        sentinel community surveillance systems. This will become the
        strong foundation of a community-driven process of developing a
        comprehensive system of care, based on local issues and
        strengths.

    b.  Meanwhile, develop and implement management information systems
        to collect data for analysis, evaluation and future policy
        development in the long term.

    c.  Incorporate health human resource planning, with population
        health and health service delivery data in order to ensure
        adequate, continuous support for the program.

2.  Ensure that local Aboriginal women and leaders are involved in
    program development and implementation. This is key to
    sustainability and success.

3.  Develop a retention strategy for health care providers that will
    make First Nations Health a "magnet" career. For example, living
    conditions for providers working on reserve must be eliminated as a
    source of attrition.

4.  Develop professional educational supports (midwifery, advanced
    practice nursing, doula, lay home visitors, medicine etc.) through
    links with academic centers and continuing education opportunities.

5.  Integrate existing programs under the broad umbrella of maternal
    child health strategy to realize efficiencies and improve
    effectiveness.

6.  Consult with provincial and territorial governments on the
    integration and funding of secondary and tertiary services
    (hospitals and doctors).

[Program Evaluation]{.underline}

Key indicators of comprehensive maternal child health in Aboriginal
community must be developed and used on a community by community basis
to self-regulate policy implementation. A pathway from current
policy/practice through progressive incremental changes toward the
vision could be drafted. Communities could use indicators to
self-assess/determine their stage of development along the pathway
toward the vision of comprehensive maternal child health care. Key
markers associated with each incremental step along the pathway can be
drafted and used for self-evaluation, identification of appropriate
intervention plans and targets, and also for evaluation of outcomes of
efforts at each step.

Suggestions for categories of indicators for community based birthing
capacity include:

-   Health Provider Indicators:

1.  Stable, competent satisfied health provider staff/team

2.  Local health professionals are supportive of new policy

3.  Possess minimum level of education/competencies necessary to
    successfully implement new policy

-   Aboriginal Community Indicators:

1.  Strong local leadership/government

2.  Low rates of violence, alcoholism

3.  Local population/community (especially women) actively involved and
    committed to

> vision for maternity care;

4.  Engagement/guidance of well integrated formal and informal community
    leaders;

5.  Good participation of mothers and families in existing programs

-   System/Structural Indicators:

1.  Integrated, smoothly function information system

2.  Mechanisms linking policy and practice with research

3.  Effective links to Provincial and Territorial health care systems

[Recommendations for Research]{.underline}

Similar to other jurisdictions, the production of Aboriginal health
research in Canada has decreased between the years 87-88 and 97-98, and
remains primarily descriptive of health deficits (Sanson-Fisher, 2002).
Researchers must develop the evidence needed for change, work with
health service delivery to integrate it into practice, and develop
acceptable evaluation methods. Vision oriented intervention research,
initiated by collaborative groups of stakeholders, with adequate
timelines to work out implementation issues and demonstrate
effectiveness and congruent evaluation strategies is required to
facilitate the changes needed at individual, program, environmental and
political levels (Sanson-Fisher, 2002). Frameworks such as that
suggested by Campbell, Fitzpatrick, Haines, Kinmouth, Sandercock,
Spiegelhalter and Tyrer, (2000) for an iterative approach to design and
evaluation of complex interventions may help negotiate through the
cultural, contextual and political challenges involved.

Specific suggestions for research and synthesis to develop an evidence
base for maternal child health care on reserve include:

-   Conduct systematic reviews of the evidence for all the promising
    alternatives.

-   Examine the variability between Aboriginal groups to enable
    identification and diffusion of innovations that seem to make a
    difference (Martens et al., 2002).

-   Models which integrate traditional and western/conventional medical
    practices warrant priority status for further attention and testing

-   Work with stakeholders to identify best practices in Aboriginal
    maternal child health care

[Next Steps]{.underline}

> Several tasks to be addressed in the next steps of developing new
> policy for maternal child health care on reserve are suggested by this
> paper. These include:

-   Form a team of stakeholders with strong leadership to guide
    development and implementation of new policy for maternal child
    health care on reserve.

-   Determine the scope and definition for maternal child health care.

-   Develop a stakeholder-based vision and take incremental steps toward
    it.

-   Involve Aboriginal people, and women in particular, in
    identifying/developing criteria for success

-   Ensure sufficient time, personnel, technical expertise and
    implementation resources are available to conduct development
    activities. Underestimation of development requirements appears to
    be a consistent weakness when implementing policy changes.

-   Establish a strong research-policy-practice-community partnership
    from the start to promote:

    -   evidence based policy

    -   community relevant policy and research, and

    -   culturally safe, evidence based practice

    -   healthy, informed participatory communities

        **Conclusion**

        This discussion paper has been written over a short period of
        time in the context of a policy practicum with Office of Nursing
        Services, First Nations and Inuit Health Branch. Concerns from
        Aboriginal people (especially women), health professionals, and
        nursing policy makers precipitated examination of maternal child
        health care on reserve. The Sabatier-Lomas policy making
        framework was used to guide collection and description of the
        information, values and structures impacting on this issue. At
        this early stage of the policy development process, a strong
        emphasis was put on collecting the evidence on both the impact
        of peri-natal development on the long health of Aboriginal
        individuals, families and communities, and on effectiveness of
        interventions focused on improving peri-natal outcomes. The
        result is a clear picture of how and why maternal child health
        care in on reserve communities must be improved. Recommendations
        for program design, implementation and evaluation are suggested.
        Several recommendations for research are included. Suggestions
        for next steps in the policy development process are pointed
        out.

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**Figure 1: Sabatier-Lomas Policy Making Framework** (Lomas, 2000)

![](media/image1.jpeg){width="6.428472222222222in" height="6.4375in"}

**Figure 3: Relationship Between Community Birthing Capacity and
Community Sustainability** (Klein et al, 2002)

1.  Women from less central communities must travel, often at great
    expense in financial and personal terms, ultimately to be cared for
    in a distant center by persons unknown.

2.  The community becomes what is known as a \"high outflow community\"
    -\> increased frequency of small premature infants and maternal and
    newborn complications due to a lack of support from family and
    friends, delays in transfer and other complex issues.

3.  Health care providers become even less satisfied with their work and
    less committed to their communities, leading to high staff turnover

4.  Other aspects of women\'s health care, such as prevention,
    counseling and office gynecology, begin to atrophy.

5.  Difficulty attracting well qualified health providers

6.  Physicians, nurses and the community itself suffer the loss of an
    entire skill-set related to reproductive and women's health.

7.  Student physicians and nurses, seeing discouraged teachers, choose
    not to enter this field of practice, selecting settings with less
    on-call and less stress. This further restricts women\'s access to
    high quality maternity care.

8.  Businesses find it difficult to recruit employees to communities
    where medical services are limited. (18-19)

9.  Many residents of the community (especially those in their
    reproductive years) begin to wonder why they are living in the
    community and try to move (many can\'t).

10. The community itself becomes dysfunctional and unstable. Maternity
    and newborn care is realized too late as being a lynch pin for
    sustainable communities, medically, socially and economically.
    Communities are caught in a cycle of dependency on outside health
    care expertise, which while providing some medical safety, is
    ineffective for supporting a healthy start for infants and families.

**Error: Reference source not foundFigure 2:**

**Safe Motherhood Framework for Assessing and Analyzing Maternal
Health**

Source: UNICEF (1999). [International Guidelines for Safe
Motherhood]{.underline}. New York: Author.

**Figure 4: Geographical Distribution of the Aboriginal Population**

![](media/image2.png){width="6.776388888888889in"
height="6.914583333333334in"}

Source: Natural Resources Canada (2002). Atlas of Canada: Aboriginal
population-1996. Available:
<http://www.aboriginalcanada.gc.ca/abdt/interface/interface2.nsf/LaunchFrameSet?OpenAgent&RefDoc=12.html&URL=http://atlas.gc.ca/site/english/maps/peopleandsociety/aboriginalpopulation/subdivision&altlang=http://atlas.gc.ca/site/francais/maps/peopleandsociety/aboriginalpopulation/subdiv>ision&disp=e&end

**Figure 5: Pathway of Effects between Peri-Natal Development and Life
Long Health**

+-----------------------------------------------------------------------+
| **Improved Health of the Population Group**                           |
|                                                                       |
| **Improved Living Conditions and Relationships**                      |
|                                                                       |
| **Improved Occupational Outcomes**                                    |
|                                                                       |
| **Success in School/Educational Attainment**                          |
|                                                                       |
| **Enhancing Readiness for School**                                    |
|                                                                       |
| **Positive Environment during Early Childhood**                       |
+-----------------------------------------------------------------------+
| **Strong Neurobiological Foundation during Fetal and Infant           |
| Development**                                                         |
|                                                                       |
| **Supportive Environment for Pregnant Women and Families**            |
+-----------------------------------------------------------------------+

**Figure 6: Emphases in High Quality Maternal Child HealthCare**

**Error: Reference source not found**

**Figure 7:**

**Stakeholders to Maternal Child Health Care in On Reserve Aboriginal
Communities**

**Table 4: Examples of Impact of Maternal Evacuation on Health**

+----------+-----------------------------------------------------------+
|          | Examples of Impact on Health and Development              |
+----------+-----------------------------------------------------------+
| Mother   | -   barrier to early recruitment (mothers hide pregnancy  |
|          |     for as long as possible)                              |
|          |                                                           |
|          | -   lost opportunity for screening and intervention for   |
|          |     variety of risk factors (biomedical, domestic         |
|          |     violence, alcohol and tobacco use, nutrition, social  |
|          |     support)                                              |
|          |                                                           |
|          | -   interferes with development of trusting relationship  |
|          |     and therefore loss of window of opportunity for new   |
|          |     attitudes and behaviors re: health                    |
|          |                                                           |
|          | -   loss of support and intervention necessary to         |
|          |     successfully manage birth, post partum recovery,      |
|          |     establish breastfeeding and make transition to        |
|          |     parenting role                                        |
|          |                                                           |
|          | -   increased stress of arduous travel, isolation in a    |
|          |     foreign environment, separation from family and       |
|          |     social support network                                |
+----------+-----------------------------------------------------------+
| Fetu     | Physical environment:                                     |
| s/Infant |                                                           |
|          | -   greater risk and exposure to toxic substances during  |
|          |     pregnancy: eg. tobacco, alcohol increases risk for    |
|          |     FAS/FAE, IUGR, and SIDS, complications at birth and   |
|          |     postpartum                                            |
|          |                                                           |
|          | -   decreased chance to receive nutritional supplements   |
|          |     needed for healthy neurodevelopment such as Folic     |
|          |     Acid to prevent neural tube defects                   |
|          |                                                           |
|          | Social/emotional environment:                             |
|          |                                                           |
|          | -   effects of increased maternal stress during pregnancy |
|          |     can contribute to low birth weight and intrauterine   |
|          |     growth retardation                                    |
|          |                                                           |
|          | -   increased maternal stress during birth can lead to    |
|          |     more birth complications, delayed recovery, and       |
|          |     increased risk for postpartum depression: this        |
|          |     interferes with maternal-infant attachment            |
|          |                                                           |
|          | -   separation from father during the crucial first week  |
|          |     postpartum significantly interferes with              |
|          |     father-infant attachment                              |
+----------+-----------------------------------------------------------+
| Family   | -   compromised father-infant attachment contributes to   |
|          |     difficulty engaging in parent role, increased risk    |
|          |     for abuse and neglect, ....                           |
|          |                                                           |
|          | -   Separation of mother from other children for          |
|          |     prolonged period contributes to family stress,        |
|          |     behavioral difficulties in siblings, and difficulty   |
|          |     accepting new infant into the family                  |
|          |                                                           |
|          | -   Lack of supportive interventions (eg. to decrease     |
|          |     maternal fatigue, facilitate family transition and    |
|          |     preparation for new baby) contributes to increased    |
|          |     family stress during pregnancy and postpartum, and    |
|          |     increased risk of family violence and child           |
|          |     abuse/neglect                                         |
+----------+-----------------------------------------------------------+
| C        | -   Loss of opportunity for community healing and         |
| ommunity |     significant symbolic opportunity for regeneration of  |
|          |     traditional cultural knowledge and values             |
|          |                                                           |
|          | -   Evacuation or loss of locally managed birthing        |
|          |     precipitates a negative cascade that undermines the   |
|          |     social and economic viability of communities: **See   |
|          |     inset: Safe Maternity Care and Community              |
|          |     Sustainability**                                      |
+----------+-----------------------------------------------------------+

**Table 6: Selected Maternal-Child Health Indicators**

+----------------------------------+-----------------+-----------------+
| **Indicator**                    | **Aboriginal    | **Canadian      |
|                                  | People**[^4]    | P               |
|                                  |                 | opulation**[^5] |
+----------------------------------+-----------------+-----------------+
| **Maternal/Neonatal Indicators** |                 |                 |
+----------------------------------+-----------------+-----------------+
| \% population under 15 years     | 38 %            | 21              |
+----------------------------------+-----------------+-----------------+
| \% children living in single     | 32%             | 13              |
| parent homes                     |                 |                 |
+----------------------------------+-----------------+-----------------+
| \% children with mothers \< 18   | 9%              | 1%              |
| years                            |                 |                 |
+----------------------------------+-----------------+-----------------+
| \% low birth weight              | 5.4%[^6]        | 5.7%            |
+----------------------------------+-----------------+-----------------+
| \% high birth weight             | Males-21.7%     | Males- 15.9%    |
|                                  |                 |                 |
|                                  | Females-14%     | Females- 8.1%   |
+----------------------------------+-----------------+-----------------+
| **Infant and Child Health        |                 |                 |
| Indicators**                     |                 |                 |
+----------------------------------+-----------------+-----------------+
| \% children up to 2 years ever   | 54%             | 75%             |
| being breastfed                  |                 |                 |
+----------------------------------+-----------------+-----------------+
| \% children under 2 breastfed \> | 39%             | 24%             |
| 6 months                         |                 |                 |
+----------------------------------+-----------------+-----------------+
| \% parents rating child health   | 16%             | 2%              |
| as poor/fair                     |                 |                 |
+----------------------------------+-----------------+-----------------+
| \% parents rating child health   | 84%             | 88%             |
| as excellent or very good        |                 |                 |
+----------------------------------+-----------------+-----------------+
| Prevalence of allergies          | 13%             | 0-11 years -14% |
+----------------------------------+-----------------+-----------------+
| Rates of Bronchitis              | 0-5 years-9%    | 0-11 years- 3%  |
|                                  |                 |                 |
|                                  | 6-11 years-5%   |                 |
|                                  |                 |                 |
|                                  | 12+ years-6%    |                 |
+----------------------------------+-----------------+-----------------+
| Rates of asthma                  | 0-5 years-15%   | 0-11 years -11% |
|                                  |                 |                 |
|                                  | 6-11 years-11%  |                 |
|                                  |                 |                 |
|                                  | 12+ years-9%    |                 |
+----------------------------------+-----------------+-----------------+
| \% children smoking by age 15    | Inuit 69% [^7]  |                 |
+----------------------------------+-----------------+-----------------+
| Infant mortality[^8] from        | 63              | 17              |
| injuries/100, 000                |                 |                 |
+----------------------------------+-----------------+-----------------+
| Infant mortality (all            | 1200            | 580             |
| causes)/100, 000                 |                 |                 |
+----------------------------------+-----------------+-----------------+
| Preschool mortality from         | 83              | 15              |
| injuries/100, 000                |                 |                 |
+----------------------------------+-----------------+-----------------+
| Teenage mortality from           | 176             | 48              |
| injury/100, 000                  |                 |                 |
+----------------------------------+-----------------+-----------------+
| **Mental Health**                |                 |                 |
+----------------------------------+-----------------+-----------------+
| \% teenagers reporting feeling   | Inuit 35% [^9]  |                 |
| unhappy/ depressed               |                 |                 |
+----------------------------------+-----------------+-----------------+
| Suicide Rates:                   | Inuit           | 1               |
|                                  | males-10X[^10]  |                 |
| Youth (1991):                    |                 | approx          |
|                                  | 37/100,000[^11] | 7/100,000       |
+----------------------------------+-----------------+-----------------+

**Table 6:** **Selected Maternal-Child Health Indicators** *(continued)*

+----------------------------------+-----------------+-----------------+
| **Family Health Status**         |                 |                 |
+----------------------------------+-----------------+-----------------+
| \% children reporting getting    | 76%             | 88%             |
| along well with family           |                 |                 |
+----------------------------------+-----------------+-----------------+
| \% children being taken into     | 4X[^12]         | 1               |
| foster care                      |                 |                 |
+----------------------------------+-----------------+-----------------+
| \% children born with FAS/FAE    | 10%[^13]        | .033 %          |
+----------------------------------+-----------------+-----------------+
| **Key/Related Determinants of    |                 |                 |
| Health**                         |                 |                 |
+----------------------------------+-----------------+-----------------+
| **Housing**                      |                 |                 |
+----------------------------------+-----------------+-----------------+
| \% population with adequate      | 54% (on         | 80%[^15]        |
| housing                          | reserve)[^14]   |                 |
+----------------------------------+-----------------+-----------------+
| **Education**                    |                 |                 |
+----------------------------------+-----------------+-----------------+
| \% never completing high school  | 64%[^16]        | 31%             |
+----------------------------------+-----------------+-----------------+
| **Economic Status**              |                 |                 |
+----------------------------------+-----------------+-----------------+
| \% below LICO                    | 44 (off         | 20              |
|                                  | reserve)[^17]   |                 |
+----------------------------------+-----------------+-----------------+
| \% \> 15 years reporting food    | Inuit-12.7[^18] | 7.5%            |
| security problems                |                 |                 |
+----------------------------------+-----------------+-----------------+
| Average employment income        | 14, 055 (on     | 26,474          |
|                                  | reserve)[^19]   |                 |
|                                  |                 |                 |
|                                  | 18, 463 (off    |                 |
|                                  | reserve)        |                 |
+----------------------------------+-----------------+-----------------+
| Unemployment rate of \> 15 years | 31% (on         | 10%             |
| (1991)                           | reserve)[^20]   |                 |
+----------------------------------+-----------------+-----------------+
| \% children 0-6 living in low    | 60%[^21]        | 25%             |
| income families                  |                 |                 |
+----------------------------------+-----------------+-----------------+

**Appendix A: Stakeholder Consultations**

+---------+------------+------------------------+---------------------+
| Name    | P          | Affiliation and        | Consultation Method |
|         | rofession/ | Co-ordinates           |                     |
|         |            |                        |                     |
|         | P          |                        |                     |
|         | erspective |                        |                     |
+---------+------------+------------------------+---------------------+
| K       | Nurse      | Executive Director,    | Focus group         |
| athleen |            | Office of Nursing      |                     |
| Ma      | Anth       | Services, First        | Face to face        |
| cMillan | ropologist | Nations and Inuit      | meetings            |
|         |            | Health Branch (FNIHB), |                     |
|         |            | Health Canada          | Email and telephone |
|         |            |                        | consultation        |
|         |            |                        |                     |
|         |            |                        | Feedback on paper   |
|         |            |                        | development         |
+---------+------------+------------------------+---------------------+
| K       | Policy     | Policy and Research    | Focus group         |
| athleen | Analyst    | Analyst, Society of    |                     |
| M       |            | Obstetricians and      | Face to face        |
| cGovern |            | Gynecologists of       | meetings;           |
|         |            | Canada (SOGC)          |                     |
|         |            |                        | Email and telephone |
|         |            |                        | consultation        |
|         |            |                        |                     |
|         |            |                        | Feedback on paper   |
|         |            |                        | development         |
+---------+------------+------------------------+---------------------+
| Nancy   | Nurse      | Director, Center for   | Face to face        |
| Edwards | Researcher | Multiple               | meetings            |
|         |            | Interventions,         |                     |
|         |            | Institute of           | Email and telephone |
|         |            | Population Health,     | consultation        |
|         |            | University of Ottawa   |                     |
|         |            |                        | Feedback on paper   |
|         |            | And Director,          |                     |
|         |            | Community Health       |                     |
|         |            | Research Unit,         |                     |
|         |            | Province of Ontario    |                     |
+---------+------------+------------------------+---------------------+
| Janet   | Aboriginal | SOGC, National         | Focus group         |
| Smylie  | Physician  | Aboriginal Health      |                     |
|         |            | Organization (NAHO),   | Email consultation  |
|         |            | Department of Family   |                     |
|         |            | Physicians, Faculty of |                     |
|         |            | Medicine, University   |                     |
|         |            | of Ottawa              |                     |
+---------+------------+------------------------+---------------------+
| Yvonne  | Aboriginal | Senior Policy Analyst, | Focus group         |
| Boyer   | Health     | NAHO                   |                     |
|         | Policy     |                        |                     |
|         | Analyst    |                        |                     |
+---------+------------+------------------------+---------------------+
| Bernice | Health     | Executive Director,    | Telephone and email |
| Downey  | Executive  | Aboriginal Nurses      | consultation        |
|         |            | Association of Canada  |                     |
|         | Aboriginal |                        |                     |
+---------+------------+------------------------+---------------------+
| Jane    | Nurse,     | Primary Health Care    | Focus group         |
| Ma      | Policy     | Consultant, Canadian   |                     |
| cDonald | Analyst    | Nurses Association     |                     |
+---------+------------+------------------------+---------------------+
| Carol   | Aboriginal | SOGC,                  | Focus group         |
| Couchie | Midwife    |                        |                     |
|         |            | Midwife, The Pas,      | Email and telephone |
|         |            | Manitoba               | consultation        |
+---------+------------+------------------------+---------------------+
| Nicki   | Nurse,     | Primary Health Care    | Face to face        |
| Sim     | Senior     | Division, FNIHB,       | meetings (3)        |
| s-Jones | Policy     | Health Canada          |                     |
|         | Analyst    |                        | Email and telephone |
|         |            |                        | consultations       |
+---------+------------+------------------------+---------------------+
| Maria   | Nurse,     | Programs and Service   | Focus group         |
| McN     | Senior     | Delivery, Office of    |                     |
| aughton | Nursing    | Nursing Services,      | Face to face        |
|         | Consultant | FNIHB, Health Canada   | meetings            |
|         |            |                        |                     |
|         |            |                        | Email and telephone |
|         |            |                        | consultation        |
+---------+------------+------------------------+---------------------+
| Judy    | Midwife    | Ryerson Polytechnical  | Email consultation  |
| Norris  |            | University             |                     |
+---------+------------+------------------------+---------------------+
| Vicki   | Midwife    | Inukjuak CLSC,         | Email consultation  |
| Van     |            |                        |                     |
| Wagner  |            | Inukjuak, PQ JOM 1M0   |                     |
+---------+------------+------------------------+---------------------+
| Lesley  | Midwife    | Private consultant?,   | Email consultation  |
| P       |            |                        |                     |
| aulette |            | NWT/ALTA-NWT           |                     |
+---------+------------+------------------------+---------------------+
| Della   | Midwife    | Midwifery Services,    | Email consultation  |
| S       |            | World Health           |                     |
| herratt |            | Organization, Geneva,  |                     |
|         |            | Switzerland            |                     |
+---------+------------+------------------------+---------------------+

**Appendix A: Stakeholder Consultations** *(continued)*

+---------+------------+------------------------+---------------------+
| *       | **Pro      | **Affiliation**        | **Method of         |
| *Name** | fession/** |                        | Consultation**      |
|         |            |                        |                     |
|         | **Per      |                        |                     |
|         | spective** |                        |                     |
+---------+------------+------------------------+---------------------+
| Mina    | Aboriginal | Co-ordinator ,         | Telephone and email |
| Tulugak | Midwife    | Midwifery Services,    | (messages left      |
|         |            |                        | X3)-no response You |
|         |            | Povungnituq and        | might want to leave |
|         |            | Inukjuak               | this out --         |
|         |            |                        | potentially         |
|         |            |                        | embarrassing for    |
|         |            |                        | individual          |
+---------+------------+------------------------+---------------------+
| Katsi   | Aboriginal | Co-ordinator,          | Telephone and email |
| Cook    | Midwife    | Iewirokas Program,     | (messages left      |
|         |            | Akwasasne First Ntion  | X3)-no response     |
|         |            |                        |                     |
|         |            |                        | Same as above       |
+---------+------------+------------------------+---------------------+
| Jenny   | Nurse,     | Associate Professor,   | Face to face        |
| Medves  | r          | Faculty of Nursing,    | meeting             |
|         | esearcher, | Queens University      |                     |
|         | Midwife    |                        | Email consultation  |
+---------+------------+------------------------+---------------------+
| Shirley | Nurse      | Principle              | Email consultation  |
| Hiebert | Pra        | Investigator, Nelson   |                     |
|         | ctitioner, | House (Manitoba)       | Telephone           |
|         |            | Participatory Research | discussion          |
|         |            | Project                |                     |
|         |            |                        |                     |
|         |            | Community Health       |                     |
|         |            | Sciences, University   |                     |
|         |            | of Manitoba            |                     |
+---------+------------+------------------------+---------------------+
| Chris   | Midwife,   | New Zealand            | Email consultation  |
| Hendry  |            |                        |                     |
+---------+------------+------------------------+---------------------+
| Ernie   | Elder,     | Aboriginal Healing     | Lunch time          |
| B       | Akwasasne  | Center                 | discussion session  |
| enedict | Band       |                        |                     |
|         |            |                        | Face to face        |
|         |            |                        | meeting             |
+---------+------------+------------------------+---------------------+
| M       | Nurse      | Regional Nursing       | Face to face        |
| ariette | Manager    | Officer, Quebec        | meeting             |
| Bobbish |            | Region, FNIHB          |                     |
|         |            |                        | Email consultations |
+---------+------------+------------------------+---------------------+
| Michel  | Nurse      | Regional Nursing       | Telephone and email |
| Pinard  | Manager    | Officer, Ontario       | consultation        |
|         |            | Region, FNIHB          |                     |
+---------+------------+------------------------+---------------------+
| Liette  | Nurse      | Zone Nursing Officer,  | Telephone and email |
| Cere    | Manager    | Moose Factory Zone,    | consultation        |
|         |            | Ontario Region, FNIHB  |                     |
+---------+------------+------------------------+---------------------+
| Lynn    | Nurse      | Zone Nursing Officer,  | Telephone and email |
| Button  | Manager    | Sioux Lookout Zone,    | consultation        |
|         |            | Ontario Region, FNIHB  |                     |
+---------+------------+------------------------+---------------------+
| Connie  | Nurse      | Regional Nursing       | Email consultation  |
| Mac     | Manager    | Officer, Atlantic      |                     |
| Pherson |            | Region, FNIHB          |                     |
+---------+------------+------------------------+---------------------+
| Sari    | Policy     | Women's Health Branch, | Email and telephone |
| Tudiver | Analyst    | Health Canada          | consultation        |
+---------+------------+------------------------+---------------------+
| Doris   | Policy     | Population and Public  | Telephone           |
| Cook    | Analyst,   | Health Branch, Health  | Discussion          |
|         |            | Canada                 |                     |
+---------+------------+------------------------+---------------------+
| Dr.     | Anthr      | Director Aboriginal    | Teleconference      |
| John    | opologist, | Health Research        | discussion          |
| O'Neill |            | Center, University of  |                     |
|         |            | Manitoba               | Email follow up of  |
|         |            |                        | resources           |
+---------+------------+------------------------+---------------------+
| Sharon  | Nursing    | Health Human           | Face to face        |
| Stanton | consultant | Resources, Office of   | meetings            |
|         |            | Nursing Services,      |                     |
|         |            | FNIHB                  | Email and telephone |
|         |            |                        | consultation        |
+---------+------------+------------------------+---------------------+
| Sara    | S          | McMaster University    | Face to face        |
| Tedford | ociologist |                        | meeting             |
|         | and        | Nunavut Maternal Child |                     |
|         | Principal  | Health Study           | Email consultation  |
|         | In         |                        |                     |
|         | vestigator | (CHSRF)                |                     |
+---------+------------+------------------------+---------------------+

Appendix B: Synthesis of Evidence for Effective Maternal Child Health
Care Intervention

+---------+-----------+------------------+-----------------------------+
| Study   | Focus     | Notes            | Recommendations             |
+---------+-----------+------------------+-----------------------------+
| Elkan,  | -home     | -present strong  | Home visiting:              |
| Ke      | visiting  | arguments        |                             |
| ndrick, |           | against a        | -should be universally      |
| Hewitt, | -pre and  | targeted, high   | initiated, and flexible in  |
| Ro      | post      | risk approach    | intensity and duration,     |
| binson, | natal     | based on         | relying on guidance from    |
| et al,  |           | screening.       | families to determine       |
| 2000    | -public   |                  | frequency, intensity and    |
|         | health    | -evidence        | duration of home visiting   |
| -c      | nurses,   | suggests home    |                             |
| ombined | health    | visiting can:    | -requires a well-trained    |
| results | visitors, |                  | and dedicated staff         |
| from 6  | lay       | improve          |                             |
| sys     | support   | parenting skills | -must have realistic        |
| tematic | workers   | and the quality  | expectations (not a magic   |
| r       |           | of the home      | bullet)                     |
| eviews: |           | environment;     |                             |
|         |           | improve          | -should be sensitive to the |
|         |           | intellectual     | unique characteristics and  |
|         |           | development of   | circumstances of clients:   |
|         |           | young children,  | interventions delivered by  |
|         |           | especially among | skilled and experienced     |
|         |           | those with low   | mothers living in the       |
|         |           | birth weight;    | community may be more       |
|         |           | decrease         | culturally sensitive and    |
|         |           | incidence of     | less expensive than         |
|         |           | unintentional    | hospital based programs     |
|         |           | injury to        | delivered by health         |
|         |           | children,        | professionals               |
|         |           | improve          |                             |
|         |           | detection and    | -should have multiple goals |
|         |           | management of    |                             |
|         |           | postpartum       | -requires further           |
|         |           | depression,      | evaluation to determine     |
|         |           | enhance quality  | optimum: dose intensity;    |
|         |           | of social        | mix of home visiting in     |
|         |           | support to       | combination with other      |
|         |           | mothers; improve | interventions; levels of    |
|         |           | rates of         | support and training needed |
|         |           | breastfeeding.   | for professional,           |
|         |           |                  | paraprofessional and lay    |
|         |           | -evidence from   | providers.                  |
|         |           | economic         |                             |
|         |           | evaluation of    |                             |
|         |           | home visiting to |                             |
|         |           | parents and      |                             |
|         |           | young children   |                             |
|         |           | indicates a net  |                             |
|         |           | cost savings.    |                             |
+---------+-----------+------------------+-----------------------------+
| Com     | home      |                  |                             |
| bs-Orme | visiting  |                  |                             |
| et al   | by PHNs   |                  |                             |
| (1985)  |           |                  |                             |
+---------+-----------+------------------+-----------------------------+
| Ciliska | effe      |                  |                             |
| et al   | ctiveness |                  |                             |
| (1994)  | of home   |                  |                             |
|         | visiting  |                  |                             |
+---------+-----------+------------------+-----------------------------+
| Hodnett | socially  |                  |                             |
| (1995)  | disa      |                  |                             |
|         | dvantaged |                  |                             |
|         | mothers   |                  |                             |
|         | and       |                  |                             |
|         | infants   |                  |                             |
+---------+-----------+------------------+-----------------------------+
| Hodnett | home      |                  |                             |
| and     | based     |                  |                             |
| Roberts | support   |                  |                             |
| (1997)  | for       |                  |                             |
|         | socially  |                  |                             |
|         | disa      |                  |                             |
|         | dvantaged |                  |                             |
|         | mothers   |                  |                             |
+---------+-----------+------------------+-----------------------------+
| Olds    | preterm   |                  |                             |
| and     | and low   |                  |                             |
| Kitzman | birth     |                  |                             |
| (1993)  | weight    |                  |                             |
|         | babies    |                  |                             |
+---------+-----------+------------------+-----------------------------+
| Olds    | low       |                  |                             |
| and     | income,   |                  |                             |
| Kitzman | at-risk   |                  |                             |
| (1993)  | families  |                  |                             |
+---------+-----------+------------------+-----------------------------+
| Roberts | hom       |                  |                             |
| et al   | evisiting |                  |                             |
| (1996)  | and       |                  |                             |
|         | childhood |                  |                             |
|         | injury    |                  |                             |
+---------+-----------+------------------+-----------------------------+
| Olds    | child     |                  |                             |
| and     | injury    |                  |                             |
| Kitman  | and abuse |                  |                             |
| (1993)  |           |                  |                             |
+---------+-----------+------------------+-----------------------------+
| Ma      | child     |                  |                             |
| cMillan | abuse     |                  |                             |
| et al   |           |                  |                             |
| (1994)  |           |                  |                             |
+---------+-----------+------------------+-----------------------------+
| Hodnett | p         |                  |                             |
| (1995)  | ostpartum |                  |                             |
|         | d         |                  |                             |
|         | epression |                  |                             |
+---------+-----------+------------------+-----------------------------+
| Ray and | -p        |                  |                             |
| Hodnett | ostpartum |                  |                             |
| (1997)  | d         |                  |                             |
|         | epression |                  |                             |
+---------+-----------+------------------+-----------------------------+
| Brunton | prenatal  | -interventions   | -combination of home        |
| &       |           | to decrease low  | visiting and clinic         |
| Thomas, | low birth | birth weight     | services can have an effect |
| 2001    | weight    | have varying     |                             |
|         | p         | degrees of       | -strategies to increase     |
|         | revention | effectiveness    | early enrollment in         |
|         | in        | across age       | comprehensive service make  |
|         | ad        | groups           | the greatest difference     |
|         | olescents |                  |                             |
|         |           | -a combination   | -effectiveness of           |
|         | public    | of interventions | interventions with          |
|         | health    | and services     | adolescents and older women |
|         | s         | produced the     | may differ                  |
|         | trategies | best outcomes    |                             |
|         |           |                  | -multiple intervention      |
|         |           |                  | programs with participant   |
|         |           |                  | involvement in design and   |
|         |           |                  | intervention are needed     |
+---------+-----------+------------------+-----------------------------+
| Mueller | -Prenatal | -screening       | -screening for abuse during |
| and     |           | effective at     | pregnancy                   |
| Thomas, | -abuse    | identifying      |                             |
| 2001    | p         | pregnant women   | \- empowerment/advocacy     |
|         | revention | who were abused  | most effective approach to  |
|         |           |                  | intervention                |
|         | -public   | -empo            |                             |
|         | health    | werment/advocacy | -outreach needed to         |
|         | nursing   | approaches       | increase access to services |
|         |           | produced most    | for victims                 |
|         | -m        | positive         |                             |
|         | ainstream | outcomes         |                             |
|         | p         |                  |                             |
|         | opulation |                  |                             |
+---------+-----------+------------------+-----------------------------+
| Di      | -         | -although        | \--further research and     |
| censio, | pregnancy | research base is | well designed evaluation of |
| Guyatt  | p         | weak, some       | pregnancy prevention        |
| &       | revention | programs to      | programs for adolescents is |
| Wilan,  | in        | prevent          | needed                      |
| 1999    | ad        | pregnancy among  |                             |
|         | olescents | adolescents are  | -program design should be   |
|         |           | effective        | based on extensive input    |
|         | -m        |                  | from adolescents, community |
|         | ainstream | -programs that   | partners and key informants |
|         | p         | were of long     |                             |
|         | opulation | duration,        |                             |
|         |           | behavior         |                             |
|         |           | focused,         |                             |
|         |           | actively         |                             |
|         |           | involved         |                             |
|         |           | participants,    |                             |
|         |           | shared facts,    |                             |
|         |           | focused on       |                             |
|         |           | social           |                             |
|         |           | pressures,       |                             |
|         |           | incorporated     |                             |
|         |           | modeling and     |                             |
|         |           | skill rehearsal  |                             |
|         |           | and included     |                             |
|         |           | trained adult or |                             |
|         |           | peer leaders     |                             |
|         |           | were shown to be |                             |
|         |           | most effective   |                             |
+---------+-----------+------------------+-----------------------------+
| C       | \-        | -home visiting   | -need strong theoretical    |
| iliska, | prenatal  | an effective     | framework linking           |
| Mas     | and       | strategy for     | interventions and intended  |
| trilli, | postnatal | helping clients  | outcomes                    |
| Ploeg,  |           | access services, |                             |
| H       | -home     | especially if at | -community wide             |
| ayward, | visiting  | greater risk     | collaboration, involving    |
| B       |           |                  | multiple agencies is most   |
| runton, | -public   | -home visiting   | effective                   |
| &       | health    | more effective   |                             |
| Underwo | nursing   | in combination   | -intensive weekly home      |
| od,1999 |           | with other       | visits most effective       |
|         | -high     | strategies       |                             |
|         | risk      |                  | -greater impact with high   |
|         | po        | -prevention      | risk clients                |
|         | pulations | oriented, though |                             |
|         |           | more effective   | -further research needed to |
|         |           | with high risk   | determine effectiveness of  |
|         |           | clients          | lay vs. professional        |
|         |           |                  | visitors.                   |
+---------+-----------+------------------+-----------------------------+
| Kramer  | -Duration | -assess effects  | -exclusive breastfeeding    |
| &       | of        | of exclusive vs. | for 6 months should be      |
| Kakuma, | exclusive | mixed            | recommended as a general    |
| 2002    | brea      | breastfeeding on | policy in both developed    |
|         | stfeeding | child and        | and developing country      |
|         |           | maternal health  | settings. However,          |
|         |           | outcomes         | appropriate support and     |
|         |           |                  | intervention should be      |
|         |           | \--infants       | provided to Individual      |
|         |           | exclusively      | infants with growth or      |
|         |           | breastfed        | other health and            |
|         |           | experience less  | development.                |
|         |           | morbidity from   |                             |
|         |           | gastrointestinal |                             |
|         |           | infection, and   |                             |
|         |           | no deficits in   |                             |
|         |           | growth; mother   |                             |
|         |           | experience       |                             |
|         |           | longer           |                             |
|         |           | lactational      |                             |
|         |           | ammenorrhea      |                             |
+---------+-----------+------------------+-----------------------------+
| Villar, | -compared | -women with      | -while similar maternal and |
| C       | o         | reduced number   | perinatal outcomes and      |
| arroli, | utcomesor | of visits were   | decreased costs can be      |
| Khan-Ne | care and  | less satisfied   | achieved by less frequent   |
| elofur, | pe        | and felt their   | visits, women can be less   |
| Piaggio | rceptions | expectations     | satisfied                   |
| &       | of care   | with care were   |                             |
| Gulm    | when      | not fulfilled.   | -satisfaction was higher in |
| ezoglu, | routine   |                  | midwife/general             |
| 2002    | of        | -care provided   | practitioner led care.      |
|         | prenatal  | by               |                             |
|         | care for  | midwives/general |                             |
|         | low risk  | practitioner was |                             |
|         | pregnancy | associated with  |                             |
|         | was       | positive         |                             |
|         | varied in | perception by    |                             |
|         | f         | women.           |                             |
|         | requency, |                  |                             |
|         | timing of | -clinical        |                             |
|         | visits,   | effectiveness of |                             |
|         | and       | midwife/general  |                             |
|         | different | practitioner was |                             |
|         | types of  | similar to that  |                             |
|         | care      | of               |                             |
|         | providers | obstretic        |                             |
|         |           | ian/gynecologist |                             |
|         |           | led shared care. |                             |
+---------+-----------+------------------+-----------------------------+
| Si      | -assess   | -all types of    | -supplementary              |
| korski, | effects   | support had a    | breastfeeding support       |
| R       | of        | beneficial       | should be provided as part  |
| enfrew, | brea      | effect on the    | of routine health services  |
| P       | stfeeding | duration of any  |                             |
| indoria | support   | type             | -exclusive breastfeeding    |
| & Wade, | inte      | breastfeeding    | should be promoted is       |
| 2002    | rventions |                  | central to management of    |
|         |           | -professional    | diarrhoel illness in        |
|         |           | support had      | partially breastfed         |
|         |           | beneficial       | infants.                    |
|         |           | effect on        |                             |
|         |           | duration of both | -further research needed to |
|         |           | exclusive and    | assess effectiveness of lay |
|         |           | non-exclusive    | and professional support in |
|         |           | breastfeeding,   | different settings.         |
|         |           | and produced a   |                             |
|         |           | significant      | -research required to       |
|         |           | reduction in     | identify appropriate        |
|         |           | risk of          | training for lay and        |
|         |           | g                | professional support of     |
|         |           | astro-intestinal | breastfeeding mothers.      |
|         |           | infections and   |                             |
|         |           | ectopic eczema.  |                             |
|         |           |                  |                             |
|         |           | -lay support had |                             |
|         |           | a beneficial     |                             |
|         |           | effect on        |                             |
|         |           | reducing         |                             |
|         |           | cessation of     |                             |
|         |           | exclusive        |                             |
|         |           | breastfeeding    |                             |
+---------+-----------+------------------+-----------------------------+
| Ze      | -cost     | -describe        | -cost/benefits of           |
| retzke, | benefits  | savings in \$US  | breastfeeding should be     |
| 1997    | of        | of               | promoted to policy makers,  |
|         | brea      | breastfeeding:   | practitioners and community |
|         | stfeeding | cost savings in  | members.                    |
|         |           | disease care,    |                             |
|         |           | health           |                             |
|         |           | expenditures,    |                             |
|         |           | and household    |                             |
|         |           | expenditures.    |                             |
|         |           | Long and short   |                             |
|         |           | term health      |                             |
|         |           | benefits to both |                             |
|         |           | mother and       |                             |
|         |           | infant           |                             |
|         |           | described.       |                             |
|         |           |                  |                             |
|         |           | \--particularly  |                             |
|         |           | relevant to      |                             |
|         |           | Aboriginal       |                             |
|         |           | people is: cost  |                             |
|         |           | savings and      |                             |
|         |           | health benefit   |                             |
|         |           | related to       |                             |
|         |           | decreased        |                             |
|         |           | incidence of     |                             |
|         |           | infant diarrhea, |                             |
|         |           | otitis media,    |                             |
|         |           | juenvile onset   |                             |
|         |           | diabetes,        |                             |
|         |           | hospitzliation   |                             |
|         |           | for RSV,         |                             |
|         |           | allergies,       |                             |
|         |           | anemia,          |                             |
|         |           | infectious       |                             |
|         |           | childhood        |                             |
|         |           | diseases,        |                             |
|         |           | respiratory      |                             |
|         |           | infections and   |                             |
|         |           | sepsis. Relevant |                             |
|         |           | to maternal      |                             |
|         |           | health is        |                             |
|         |           | decreased        |                             |
|         |           | incidence of     |                             |
|         |           | diabetes, breast |                             |
|         |           | cancer, domestic |                             |
|         |           | violence,        |                             |
|         |           | osteoporosis,    |                             |
|         |           | rheumatoid       |                             |
|         |           | arthritis and    |                             |
|         |           | obesity in       |                             |
|         |           | breastfeeding    |                             |
|         |           | mothers.         |                             |
+---------+-----------+------------------+-----------------------------+
| E       | -pre and  | -clear           | -smoking cessation should   |
| dwards, | post      | dose-response    | be included in              |
| Sim     | natal     | relationship     | comprehensive prenatal      |
| s-Jones |           | between smoking  | programs                    |
| and     | -smoking  | during pregnancy |                             |
| Hotz,   | cessation | and low birth    | -attendance at group        |
| 1996    |           | weight           | interventions was poor      |
|         | -trained  |                  |                             |
|         | health    | -smoking         | -training of health care    |
|         | prof      | cessation        | providers to provide        |
|         | essionals | interventions    | individual counseling to    |
|         |           | can reduce       | pregnant women is effective |
|         | -main     | incidence of     |                             |
|         | stream    | smoking          |                             |
|         | p         |                  |                             |
|         | opulation |                  |                             |
+---------+-----------+------------------+-----------------------------+
| Blythe, | -mater    |                  | -Communities should be      |
| 1995    | nal-child |                  | encouraged to provide       |
|         | health    |                  | direction for their own     |
|         | care      |                  | health care                 |
|         | programs  |                  |                             |
|         | for 0-6   |                  | -research is needed into    |
|         | p         |                  | ways to improve             |
|         | opulation |                  | intercultural communication |
|         | and       |                  | between health care         |
|         | families  |                  | professionals and native    |
|         | in        |                  | people                      |
|         | A         |                  |                             |
|         | boriginal |                  | -culturally appropriate     |
|         | co        |                  | health education tools must |
|         | mmunities |                  | be developed                |
|         |           |                  |                             |
|         |           |                  | -program evaluation is      |
|         |           |                  | essential, further work     |
|         |           |                  | must be done to develop     |
|         |           |                  | culturally appropriate      |
|         |           |                  | evaluation tools and        |
|         |           |                  | techniques                  |
|         |           |                  |                             |
|         |           |                  | -need to invest in          |
|         |           |                  | knowledge transfer          |
|         |           |                  | strategies re:              |
|         |           |                  | effectiveness of            |
|         |           |                  | interventions in Aboriginal |
|         |           |                  | populations and communities |
|         |           |                  |                             |
|         |           |                  | -further investigation      |
|         |           |                  | needed into                 |
|         |           |                  | maternal-childcare needs of |
|         |           |                  | Inuit, Metis, and Innu      |
|         |           |                  | people                      |
+---------+-----------+------------------+-----------------------------+
| Tu      | -efficacy |                  |                             |
| rnbull, | of        |                  |                             |
| Holmes, | midwife   |                  |                             |
| S       | managed   |                  |                             |
| hields, | vs,       |                  |                             |
| Cheyne  | shared    |                  |                             |
| et al,  | (eg.      |                  |                             |
| 1996    | midwives, |                  |                             |
|         | doctors   |                  |                             |
|         | and and   |                  |                             |
|         | GPs) care |                  |                             |
|         | in low    |                  |                             |
|         | risk      |                  |                             |
|         | women     |                  |                             |
+---------+-----------+------------------+-----------------------------+
| Homer,  | -RCT      | -emphasis on     | -caesarean section rates    |
| Davis,  | testing   | continuity of    | chosen as a primary         |
| Brodie, | if        | care from a      | indicator of quality of     |
| S       | commun    | consistent TEAM  | maternity care              |
| heehan, | ity-based | of midwives and  |                             |
| B       | model of  | an obstetrician, |                             |
| arclay, | c         | rather than      |                             |
| Wills & | ontinuous | carer or midwife |                             |
| C       | care      |                  |                             |
| hapman, | provided  | -several points  |                             |
| 2001    | by        | in the protocol  |                             |
|         | midwives  | provided choices |                             |
|         | and       | to women         |                             |
|         | obst      | regarding their  |                             |
|         | etricians | care             |                             |
|         | improved  |                  |                             |
|         | maternal  | -caesarean       |                             |
|         | outcomes  | section rates    |                             |
|         |           | chosen as a      |                             |
|         | -met      | primary          |                             |
|         | ropolitan | indicator of     |                             |
|         | Sydney    | quality of       |                             |
|         |           | maternity care   |                             |
|         | -mult     |                  |                             |
|         | icultural |                  |                             |
|         | p         |                  |                             |
|         | opulation |                  |                             |
|         |           |                  |                             |
|         | -low risk |                  |                             |
|         | pr        |                  |                             |
|         | egnancies |                  |                             |
+---------+-----------+------------------+-----------------------------+
| Klein,  | Impact of | -delivery        | Appropriate referral,       |
| Spence, | delivery  | volumes of       | training and continuing     |
| Kaczo   | volumes   | family           | education are key to        |
| rowski, | of family | physicians were  | responsible safe practice   |
| Kelly   | p         | not associated   | of FP with low delivery     |
| and     | hysicians | with adverse     | volumes.                    |
| Gr      | on birth  | maternal or      |                             |
| ybowski | outcomes  | newborn outcomes |                             |
| (2002)  |           |                  |                             |
+---------+-----------+------------------+-----------------------------+
| C       | -a        | -women satisfied | -having a trusting          |
| lement, | ssessment | with reduced     | relationship with care      |
| Si      | of        | care were more   | provider is key to women's  |
| korski, | p         | likely to live   | satisfaction with care      |
| Wilson, | redictors | in rented        |                             |
| Das &   | (dem      | accommodation,   | -necessary to talk to women |
| S       | ographic, | and have a       | individually and tailor     |
| meeton, | o         | caregiver that   | their care to their         |
| 1996    | bstetric, | listened to them | particular preferences and  |
|         | maternity | and encouraged   | needs                       |
|         | care,     | them to ask      |                             |
|         | practical | questions        | -improving the quality of   |
|         | and       |                  | psychosocial care during    |
|         | at        | -womenare        | pregnancy may be a good     |
|         | titudinal | depended on      | strategy for making reduced |
|         | v         | living s         | visit schedules more        |
|         | ariables) |                  | acceptable to women         |
|         | for       |                  |                             |
|         | women's   |                  |                             |
|         | sat       |                  |                             |
|         | isfaction |                  |                             |
|         | with      |                  |                             |
|         | tr        |                  |                             |
|         | aditional |                  |                             |
|         | and       |                  |                             |
|         | reduced   |                  |                             |
|         | antenatal |                  |                             |
|         | visit     |                  |                             |
|         | schedules |                  |                             |
+---------+-----------+------------------+-----------------------------+
| Wiist & | -effe     | -protocol        | -abuse assessment protocols |
| McF     | ctiveness | increased abuse  | should be a routine part of |
| arlane, | of abuse  | assessment from  | maternity care              |
| 1999    | a         | 0-88%.           |                             |
|         | ssessment |                  |                             |
|         | protocol  | -Detection       |                             |
|         | in        | increased from   |                             |
|         | prenatal  | 0.7% to 8%       |                             |
|         | clinics   |                  |                             |
|         |           | -referral        |                             |
|         | -         | increased        |                             |
|         | primarily |                  |                             |
|         | latina    | -protocol        |                             |
|         | p         | implementation   |                             |
|         | opulation | included 90      |                             |
|         |           | minute inservice |                             |
|         | -multidis | education        |                             |
|         | ciplinary | sessions         |                             |
|         | public    |                  |                             |
|         | health    |                  |                             |
|         | staff     |                  |                             |
+---------+-----------+------------------+-----------------------------+
| W       | -effe     | -application of  | -consensus                  |
| indsor, | ctiveness | organizational   | development-quality         |
| Woodby, | of        | development and  | improvement philosophy      |
| Miller  | smoking   | quality          | critical to formation of    |
| et al,  | reduction | improvement      | partnerships at all levels  |
| 2000    | practice  | theory at        |                             |
|         | g         | management and   | -strong productive          |
|         | uidelines | clinical         | practice-science linkages   |
|         | and       | practice levels  | must be created to support  |
|         | patient   | significantly    | practice                    |
|         | education | increased        |                             |
|         | methods   | smoking          | -all aspects: policy,       |
|         |           | cessation rates  | structure, content,         |
|         | -medicaid |                  | process, training sessions, |
|         | clients   | -multiple        | evaluation strategies, must |
|         |           | intervention     | be developed through a      |
|         |           |                  | flexible consensus building |
|         |           | -used process    | approach to allow optimal   |
|         |           | and impact       | use of stakeholder          |
|         |           | evaluation       | knowledge                   |
|         |           | methods          |                             |
|         |           |                  | -sufficient time,           |
|         |           |                  | personnel, technical        |
|         |           |                  | expertise and               |
|         |           |                  | implementation resources    |
|         |           |                  | must be available to        |
|         |           |                  | conduct development         |
|         |           |                  | activities                  |
+---------+-----------+------------------+-----------------------------+
|         |           |                  |                             |
+---------+-----------+------------------+-----------------------------+
| A       | -Pre and  | Culturally       | Women often afraid to ask   |
| ffonso, | postnatal | based,           | questions. Culturally       |
| Ma      | care      | interactive      | appropriate methods for     |
| yberry, |           | method for       | engagement in care,         |
| Inaba,  | -Public   | psychosocial     | assessment, education,      |
| Matsuno | health    | assessment and   | problem solving and         |
| &       | nurses    | management       | intervention for women to   |
| Ro      |           | during the pre   | discuss psychosocial needs  |
| binson, | -ethnic   | and post natal   | and concerns important in   |
| 1996    | minority  | period; also     | early recruitment into      |
|         | women     | used to increase | prenatal care,              |
|         |           | recruitment and  | effectiveness of care, and  |
|         |           | retention of     | particularly in prevention  |
|         |           | women into pre   | of PPD.                     |
|         |           | and post natal   |                             |
|         |           | care programs    |                             |
+---------+-----------+------------------+-----------------------------+
| A       | -public   | Describes role   | -local leaders from groups  |
| ffonso, | health    | functions,       | most vulnerable for low     |
| Ma      | nurses    | training, and    | birth weight recruited on   |
| yberry, |           | evaluation       | basis of maturity,          |
| Inaba,  | -lay      | methods in a     | flexibility, culturally     |
| R       | health    | successful model | sensitive communication     |
| obinson | workers   | for involving    | skills, sense of compassion |
| &       |           | local women as   | and interest in the         |
| Matsu   | -ethnic   | partners with    | community, rather than      |
| na,1995 | minority  | public health    | expertise in the health     |
|         | women     | nurses in a      | field. Critical factors     |
|         |           | small rural      | were willingness to enter   |
|         | \-        | community.       | the life world of local     |
|         |           | Specifically     | women, build team cohesion  |
|         |           | aimed to promote | through joint training      |
|         |           | respect for and  | strategies, recognize and   |
|         |           | integration of   | build on community          |
|         |           | cultural/ethnic  | strengths, use              |
|         |           | ways of knowing  | participatory dialogue to   |
|         |           | and healing into | design program, elicit and  |
|         |           | maternity care   | incorporate community and   |
|         |           |                  | client opinion on program   |
|         |           |                  | goals and protocols, hold   |
|         |           |                  | regular team meetings to    |
|         |           |                  | address common problems and |
|         |           |                  | issues, and recruit ongoing |
|         |           |                  | to avoid burnout of lay     |
|         |           |                  | volunteers.                 |
+---------+-----------+------------------+-----------------------------+
| A       | -prenatal | A culturally     |                             |
| ffonso, | care      | responsive,      |                             |
| Ma      |           | woman-centered   |                             |
| yberry, | -public   | model of         |                             |
| Graham, | health    | prenatal care    |                             |
| S       | nurses    | that uses        |                             |
| hibuya, |           | tr               |                             |
| K       |           | imester-specific |                             |
| unimoto |           | adaption themes  |                             |
| and     |           | to develop       |                             |
| K       |           | meaning, mastery |                             |
| uramoto |           | and self-esteem  |                             |
| (1992)  |           | in preparation   |                             |
|         |           | for birth and    |                             |
|         |           | motherhood.      |                             |
+---------+-----------+------------------+-----------------------------+
| De      | -midwives | Women receiving  | -organization of work (eg.  |
| Konick, |           | midwifery care   | salaried vs. fee for        |
| Blais,  | -p        | were more likely | service), and philosophy    |
| J       | hysicians | to report        | and approach of midwives    |
| oubert, |           | perception of    | favor woman-centered and    |
| Gagnon  | -         | more             | personalized care necessary |
| et      | prenatal, | personalized     | to obtain better outcomes   |
| equipe, | birth and | care, had        | (eg. breastfeeding,         |
| 2001    | postnatal | greater number   | confidence with infant      |
|         |           | and length of    | care, satisfaction with     |
|         |           | prenatal visits, | maternity care)             |
|         |           | and higher rates |                             |
|         |           | of breastfeeding |                             |
|         |           | than women       |                             |
|         |           | receiving        |                             |
|         |           | standard         |                             |
|         |           | physician        |                             |
|         |           | services, though |                             |
|         |           | selection bias   |                             |
|         |           | may be a factor  |                             |
|         |           | in differences   |                             |
|         |           | between groups.  |                             |
+---------+-----------+------------------+-----------------------------+
|         |           |                  |                             |
+---------+-----------+------------------+-----------------------------+

[^1]: The most recent edition of Community Health Program Manuals from
    Pacific Region (1998), Saskatchewan Region (1996), Manitoba Region
    (1995), and Quebec Region (1987) were reviewed.

[^2]:

[^3]: "The acronym CIET comes from the name of the research centre in
    Mexico where the organization began in 1985: Centro de Investigación
    de Enfermedades Tropicales (Tropical Disease Research Centre). When
    CIET registered in February 1994 as a non-profit, non-governmental
    organization based in New York, the name became \"Community
    Information and Epidemiological Technologies,\" reflecting the
    broader application of epidemiological methods to research areas
    beyond the health field. More recently in South Africa and Europe
    CIET has come to stand for "Community Information, Empowerment,
    Transparency."" (CIET, (2002).

[^4]: Assembly of First Nations (1999) unless otherwise indicated

[^5]: F/T/P Advisory Committee on Population Health (F/T/P ACPH) (1999)
    unless otherwise indicated

[^6]: Standards used to measure and rate low birth weight (LBW) were
    developed using non-naïve populations. "There is some evidence to
    suggest that First Nations and Inuit infants may have growth
    patterns that differ from the majority culture. ..if Aboriginal's
    have a higher weight for height growth pattern, then a weight of
    2500 grams may be set too low for the First Nations population in
    capturing infants at increased risk of health problems" (MacMillan
    et al., 1999).

[^7]: Pauktuutit, (1995b), cited in Dion-Stout and Kipling (1999)

[^8]: Morbidity rates for injuries were calculated on different time
    scales in the two studies, and were therefore not comparable.

[^9]: Moffat (1992) cited in Dion-Stout and Kipling (1999)

[^10]: Brann (1996) cited in Dion-Stout and Kipling (1999)

[^11]: MacMillan et al (1996)

[^12]: Assembly of First Nations (1994)

[^13]: from study of First Nations reserves in Manitoba (MacKenzie,
    1997), cited in Department of Indian Affairs and Northern
    Development (DIAND) (1999)

[^14]: DIAND (1999)

[^15]: Canadians paying rent living in inadequate housing, cited in
    F/P/T ACPH (1999).

[^16]: Frideres and Reeves (1993), cited in Dion-Sout and Kipling (1999)

[^17]: Budgell (2001)

[^18]: Canadian Institute of Child Health (1994)

[^19]: Statistics Canada-1996 Census: Aboriginal data, cited in Budgell
    (2001)

[^20]: MacMillan et al (1996)

[^21]: Statistics Canada-1996 Census: Sources of Income, cited in
    Budgell (2001)