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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
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Keys indicators: Maternal deaths are rare
• Maternal mortality: 2.8 deaths per year and 4.8 per 100 000 live births in 2005–2010
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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
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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
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Primary care services for families with children
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Day care
Primary
education
Secondary
education
University
University of
Applied sciences
Maternity
clinics Child health
clinics Student health care School health
care
Pre-
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.
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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
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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
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National recommendations
• THL issued new national recommendations for maternity clinics (2013)
• Extensive health examinations – A guidebook for staff (THL 2013)
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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
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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
class
• Maternity clinics – 99,8 % of families use these services
• Child health clinics – 99,5 % of families use these services
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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
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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
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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
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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
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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
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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
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At least 8-9 visits during the normal course of a pregnancy and 2 after the delivery
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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
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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
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At least 9 health visits during the first year of an infant’s life and 6 between the ages of 1 and 6
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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
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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
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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
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Source: Afifi & MacMillan 2011, Bell et al. 2013
The earlier the investment, the greater the return
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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
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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
delay
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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
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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
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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
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• 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
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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
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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
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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
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Maternity package 2015 (KELA)
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