Maternity and child health care in finland 11112015 tuovi hakulinen

transcript

Maternity and child health care in Finland

Tuovi Hakulinen, Research Manager, PhD, Adjunct Professor

Marjaana Pelkonen, Ministerial Advisor, PhD, Ministry of Social Affairs and Health

A long history of Finnish maternity and child health care

• First maternity and child health clinics were established in 1920’s

• Act on Child Care Clinics in 1944 – Municipalities had a legal obligation to provide maternity and

child health clinics services

9.5.2016 Tuovi Hakulinen 2

Keys indicators: Maternal deaths are rare

• Maternal mortality: 2.8 deaths per year and 4.8 per 100 000 live births in 2005–2010

Key indicators: Infant deaths are rare • Infant mortality rate is among the lowest in the

world; 1.8 per 1,000 live births in 2013

Family policy in Finland

• The Aim

• To create a safe environment for children to grow up and to provide parents with the material and psychological means to have and raise children

• Support for families 1. Services: health care, social welfare, education

2. Financial support

– Maternity grant: maternity package or cash lump sum

– Maternity, paternity and parental allowances

– Child benefits, housing support etc.

3. Family leave system

Primary care services for families with children

Day care

Primary

education

Secondary

education

University

University of

Applied sciences

Maternity

clinics Child health

clinics Student health care School health

primary

education

Birth 7 years 6 years 16 years 19 years

Guidance and provision of public health services

• Guidance: the Ministry of Social Affairs and Health

• Public health care services – Primary health care and specialized hospital care

• Responsibility for organising primary health services: municipalities

• Primary health care in health centres – 157 health centres in 2014

• Maternity and child health clinics • School and student health care • Dental care • Medical care, Home nursing etc.

Tuovi Hakulinen 7 9.5.2016

New legislation on maternity and child health care • The Health Care Act 1326/2010

• Government Decree 338/2011 on maternity and child health clinic services, school and student health services and preventive oral health services for children and youth

• Child Welfare Act 417/2007

• Social Welfare Act 1301/2014

– Health promotion and empowerment

– Early intervention: targeted support to those who need it

– Services should be equal in quality and take the needs of families at large into account

Guiding and supervision

• National Institute for Health and Welfare (THL) – Supports municipalities and monitors the

implementation of legislation

• National Supervisory Authority for Welfare and Health – Supervises health centres and implementation of

legislation

• Regional State Administrative Agencies – Supervise services provided in their respective

districts

National recommendations

• THL issued new national recommendations for maternity clinics (2013)

• Extensive health examinations – A guidebook for staff (THL 2013)

Funding of public health services

• The health care system is mostly funded by taxation levied by the state and the local authorities

• The sate supports municipal service provision by means of central government transfers to local government

Access to the primary health services

• Free of charge within easy reach of clients in every municipality

• Universal for all social groups, voluntary • Widely used and accepted regardless of social

• Maternity clinics – 99,8 % of families use these services

• Child health clinics – 99,5 % of families use these services

Number of births, children and adolescents • Births per year: around 60 000 Maternity health clinic services

• Children under school age (0-6 years): 420 000 Child health clinic services

• School aged children (7-15 years): 520 000/ primary school School health care services

• Students (16-18 years): 370 000/General Upper Secondary education/Vocational Upper Sec. Ed. Student health care services

• Students (over 19 years): 300 000, University education/Polytechnic education – Student health care services

Current challenges in women’s health and well-being, some examples

• Pregnancy in women over 35 years of age – Increasing risk of gestational diabetes, miscarriage,

pre-term birth, hypertensive disorders of pregnancy

• In 2011 one third of all women having given birth were overweight (BMI 25 or more) and 12 % were obese (BMI> 30)

• In 2011 some 16 % of all women have smoked during pregnancy

– Source: Nordic perinatal statistics 2012

Current challenges in children’s health

• Finnish children and families are doing well

• Psychosocial and behavioural problems, learning difficulties and obesity

• Parental mental illness, alcohol abuse, domestic violence, problems in couple relationships and unemployment Severe impacts on children’s health and

wellbeing

• Inequalities in children’s health

Maternity and child health care services

• Goals – to promote the health and wellbeing of the

pregnant mothers and their families/children and their parents and to prevent illnesses

– to reduce health inequalities between population groups

• Objectives – to monitor and support healthy pregnancy/growth

and development of children and to empower parents in caring and rearing of their children

– to identify any need for special support as early as possible

– to provide support and assistance and to refer clients to examinations and treatment when needed

Core personnel

• Core team in maternity and child health clinics – Public health nurses (or midwives in maternity

clinics) – Physicians – Family workers (social work)

• Other professionals in health centres – Psychologists, physiotherapists, speech therapists,

nutritionists, dentists

• Multiprofessional and multisectoral collaboration within the municipality – Early education (day care) – Social welfare: family work, home aid, child

protection, family counselling – Specialized health care

The purpose of maternity clinics • To secure the welfare of pregnant mothers and

unborn children and • To promote mental and psychological welfare and

health habits of the whole family

• Services include health examinations, counselling, home visits and family training – Mothers are screened for hepatitis B, syphilis, HIV

– Ultrasound scans are offered

• Close cooperation with maternity hospitals and outpatients maternity clinics

At least 8-9 visits during the normal course of a pregnancy and 2 after the delivery

Scheduled appointments at maternity clinics Appointments Parity Regular health examinations Time*

6.–8. wk P, M First contact: telephone or face to face assessment of the need

of support

15 min

8.–10. wk P, M PHN (public health nurse) or midwife

1 h 30 min

13.–18. wk P, M Extensive health examination: PHN or midwife 1 h 30 min

13.–18. wk P, M Extensive health examination: Doctor 30 min

22.–24. wk P, M PHN or midwife 30 min

26.–28. wk P PHN or midwife 30 min

30.–32. wk P, M PHN or midwife

Home visit for the first-time parents

30 min or

2 h 30 min

35.–36. wk P, M Doctor 30 min

37.–41. wk P, M PHN or midwife - Visit fortnightly or more when needed 30 min

Delivery

1.–7. d after

discharge

P, M PHN or midwife: visit to the clinic or home visit 60 min

2 h 30 min

5.–12. wk P, M Postpartum checkup: doctor or PHN or midwife 30 min

The purpose of child health clinics • To promote the health of children and the whole

family

• To monitor and support the physical, psychological and social development of the child as well as the parents’ resources and coping

• Services include health examinations, counselling, home visits and parent groups – Immunization of children in accordance with the

national vaccination programme

– Observations of growth in height and weight,

acuity of vision, hearing, speech development,

psychomotor skills, interaction with parents

21 Tuovi Hakulinen 9.5.2016

At least 9 health visits during the first year of an infant’s life and 6 between the ages of 1 and 6

Tuovi Hakulinen 22

9.5.2016

Scheduled appoinments at child health clinic Appointments Regular health examinations and actors

1-4 wk PHN (public health nurse)

4-6 wk Doctor

2 mth PHN

3 mth PHN

4 mth Extensive health examination: PHN and doctor, jointly or separately

5 mth PHN

6 mth PHN

8 mth Doctor

12 mth PHN

18 mth Extensive health examination: PHN and doctor, jointly or separately

2 yrs PHN

3 yrs PHN

4 yrs Extensive health examination: PHN and doctor, jointly or separately

5 yrs PHN

6 yrs PHN

Finnish national vaccination programme All population

Vaccine Recommended age

Rota 2 months

DTaP-IPV-Hib + Rota, PCV

3 months

DTaP-IPV-Hib + Rota, PCV

5 months

DTaP-IPV-Hib, PCV

12 months

MMR 12-18 months

HPV girls 11-12 y, catch up 13-15 y

Influenza 6-35 months (annually)

DTaP-IPV 4 years

MMR 6 years

dtap 14-15 years

dT adults, every 10 years

Risk groups

Vaccine At the earliest at age

BCG < 1 week

HBV 0 d

HAV 12 months

Influenza 6 months

TBE * 12 months

PCV 3 months

PPV 2 years

*Residents of Åland temporarily, 2006-2010

Tuovi Hakulinen 9.5.2016 24

Extensive health examinations • Assessment of the health and well-being of

parents and the entire family, introducing earlier support and strengthening empowerment of families

• At least one extensive health examination for each family expecting a baby

• Three extensive examinations for child-rearing families

• At the ages of 4 and 18 months and 4 years

• Both parents are invited along

• Jointly conducted by a PHN/midwife and a phycisian

• Source: Government Decree 338/2011 9.5.2016 25 Tuovi Hakulinen

Factors that increase well-being in children and young people

• Safe and stable adults

• A good relationship with parents

• A culture of care in upbringing

• A lifestyle that promotes health and well-being

• Knowing that you can cope

• Friends

• Predictability of everyday life and financial stability

• Parents' own well-being

• Good relationship between parents

• Sufficient family support network

• Time spent with the family

Source: Afifi & MacMillan 2011, Bell et al. 2013

The earlier the investment, the greater the return

Source: JJ Heckman 2008, 2009

Five main themes of assessment of support needs in extensive health ex:s

• Parents’ health and wellbeing – Major health problems, couple relationship, home

atmosphere

• Family members’ interaction – Interaction of parents and children, child rearing

practices, security

• Living conditions and social support – Parents’ income and employment, availability of

support

• Child’s health and wellbeing

• Siblings’ health and wellbeing

Early identification of support needs

• Regular health visits and health counselling enable early detection of needs for special support

• The nature of the relationship between the family and PHN/midwife/physician: trust, collaboration

• Interviewing parents

• Taking up one’s worries

• Use of questionnaire forms e.g. – AUDIT-test, EPDS, Family resources, Domestic

violence

• Support should be provided without

29 Tuovi Hakulinen 9.5.2016

Additional follow-up and support to those who need it 1/2 • Indicators for extra visits and support during

pregnancy:

• Mother’s chronic diseases e.g. – Asthma, mental health problems, diabetes

• Problems in pregnancy e.g.

– Risk for preterm birth, pre-eclampsia, gestational diabetes, multiple pregnancy

• Family problems and concerns e.g. • Domestic violence, substance misuse, mental health

• Pregnant mother is referred to a maternity outpatient clinic when needed

• High-risk pregnancies and deliveries are taken care in university and central hospitals

Additional follow-up and support to those who need it 2/2

• Indicators for extra visits and support during child-rearing stage:

• Concerns and problems of children e.g. • Psychosocial problems, learning difficulties, ADHD,

overweight, obesity

• Concerns and problems of parents e.g. • Mental health problems, alcohol abuse, domestic violence

• Extra visits to child health clinic, home visits, family work, peer groups

• Multiprofessional work at health centre

• Consultations and further examinations in specialised health care

National follow-ups

• New regulations, follow-ups and supervision have improved the functions of maternity and child health clinics to better meet the needs of children and families

• Both PHNs and client families have reported that extensive health examinations have been useful as they have provided an opportunity to discuss issues that would otherwise have gone unnoticed

• This allows responding to the child and family needs earlier, and providing support to those in need

• Sources: Hakulinen-Viitanen et al. 2014, Lammi-Taskula & Karvonen eds. 2014

Percentage of health centres (N=150) which arranged extensive health examinations in line with legislation

33 9.5.2016 Tuovi Hakulinen

2009: Ståhl & Saaristo 2011, 2011: Wiss et al. 2012, 2012: Hakulinen-Viitanen et al. 2014, 2013: Wiss et al. 2014

Conclusions and future challenges

• An issue – Health promotion and prevention are public

priorities (e.g. Government programme) but not always taken into account in municipal decision making

• Investments in prevention are needed but municipalities have economic difficulties due to economic recession

The reform of the social welfare and healthcare service system

• There will be 18 autonomous regions in the country,

• These regions will be responisible for organising health and social services in their area

• The changes are expected to bring substantial savings to the public finance

Government’s new programme 2015-2018

• Programme to address reform in child and family services

• Emphasis on promotion and prevention

• Participation

Benefits for families with children by KELA

• Parents are entitled to maternity, paternity and parental allowances – when one has been covered by the Finnish social

security for at least 180 days just before the estimated date of delivery

• See Social Insurance Institution (KELA) http://www.kela.fi/web/en/families

• Maternity grant – when pregnancy has lasted at least 154 days

– Certification on pegnancy is needed; given by maternity clinic or medical doctor/private sector

– Cash maternity grant (140 €) OR maternity package

Maternity package 2015 (KELA)

Thank you very much!

tuovi.hakulinen@thl.fi

Maternity and child health care in finland 11112015 tuovi hakulinen

Health & Medicine