Reproductive Health

Report to
Rapport au:
Ottawa Board of Health
Conseil de santé d’Ottawa
May 5, 2014
5 mai 2014
Submitted by
Soumis par:
Dr./Dr Isra Levy
Medical Officer of Health/Médecin chef en santé publique
Contact Person
Personne ressource:
Andrew Hendriks, Manager/Gestionnaire
Clinical Programs/Programme de Clinique
Ottawa Public Health/Santé publique Ottawa
613-580-2424 ext./poste 24151, [email protected]
and
Sherry Nigro, Manager/Gestionnaire
Health Promotion and Disease Prevention, Promotion de la santé et prévention des
maladies
Ottawa Public Health/Santé publique Ottawa
613-580-2424, ext./poste 28971, [email protected]
Ward: CITY WIDE / À L'ÉCHELLE DE LA
VILLE
File Number: ACS2014-OPH- HPDP0005
SUBJECT: HEALTHY START: PART 1 - REPRODUCTIVE HEALTH
OBJET:
DÉPART EN SANTÉ – 1RE PARTIE : SANTÉ GÉNÉSIQUE
REPORT RECOMMENDATIONS
That the Board of Health for the City of Ottawa health unit receive this report for
information.
RECOMMANDATIONS DU RAPPORT
Que le Conseil de santé de la circonscription sanitaire de la ville d’Ottawa prenne
connaissance du présent rapport à titre d’information.
EXECUTIVE SUMMARY
Early life experiences affect how children develop cognitively, socially and physically
and have lifelong effects on their health and wellbeing - from obesity, heart disease and
mental wellbeing, to school success and socioeconomic status. To support children to
have the best start in life, Ottawa Public Health (OPH) works to provide a continuum of
programs and services for families that promote early childhood development, from
preconception up to a child’s transition to school. This report, the first in a series of four
reports on early childhood development, highlights the programs and services offered
prenatally. The series of reports will also highlight the work OPH is doing with local
partners to promote early childhood health, a key social determinant of health.
Every $2 invested in early childhood education saves $7 in health, education and social
costs later in life.1 OPH leverages partnerships with other organizations to serve
children and their families in the city as effectively as possible.
Almost 10,000 babies are born every year in Ottawa. Maternal and paternal health
before and during pregnancy has a significant impact on birth outcomes including birth
weight. Both high and low birth weight are risk factors for poor health.2 To support
expectant parents, OPH offers a broad range of prenatal education opportunities.
Programs vary from online prenatal classes to small Pregnancy Circles for clients who
face barriers in accessing prenatal education services.
OPH offers prenatal support and early intervention to expectant parents facing
challenges such as physical or mental illness, language barriers, poverty or abuse.
These supports are offered by public health nurses, a social worker and family visitors
through the Healthy Babies, Healthy Children program.
OPH also has a strong commitment to promote, protect and support breastfeeding. The
decision to breastfeed is often made before conception or in the early stages of
pregnancy. OPH actively collaborates with community partners to promote and provide
access to breastfeeding resources to encourage healthy growth and development of
children.
Looking ahead, OPH will raise awareness of the importance of maternal weight and
appropriate gestational weight gain with health care providers, and adults in their
childbearing years. OPH will also expand pregnancy circles for families with barriers,
such as newcomers and those with unstable housing. To continue to support
breastfeeding mothers, OPH, the Champlain Maternal Newborn Regional Program
(CMNRP), and other service providers will be assessing their experiences with current
breastfeeding support services to better understand challenges they may have
encountered with breastfeeding.
OPH will continue to work with partners to assist future and expectant parents in
achieving healthy pregnancies, optimal birth outcomes and a positive transition to
parenting to help ensure all children in Ottawa receive a healthy start.
RÉSUMÉ
Les expériences des premières années de vie influencent le développement cognitif,
social et physique des enfants et ont durant toute leur vie des répercussions sur leur
santé et leur bien-être, allant de l’obésité, à la maladie cardiaque et à la santé mentale
à la réussite scolaire et au statut socio-économique. Pour aider les enfants à prendre un
meilleur départ dans la vie, Santé publique Ottawa s’efforce d’offrir un ensemble de
programmes et de services aux familles dans le but de favoriser le développement de la
petite enfance, de la préconception jusqu’à l’âge scolaire. Ce rapport, qui est le premier
d’une série de quatre rapports sur le développement de la petite enfance, met en
lumière les programmes et les services offerts avant la naissance. Ces rapports
souligneront également le travail que fait Santé publique Ottawa en collaboration avec
ses partenaires locaux pour promouvoir la santé de la petite enfance, un des principaux
déterminants sociaux de la santé.
Chaque deux dollars investi dans l’éducation de la petite enfance permet plus tard des
économies de sept dollars en coûts de soins de santé, d’éducation et de frais sociaux.3
Santé publique Ottawa mise sur le partenariat avec d’autres organisations pour servir
les enfants et les familles le plus adéquatement possible.
Près de 10 000 enfants naissent chaque année à Ottawa. La santé du père et de la
mère avant et pendant la grossesse a une influence considérable sur l’issue de la
grossesse, y compris sur le poids du bébé. Tant un poids élevé qu’un poids faible à la
naissance constituent des facteurs de risque de mauvaise santé.4 Pour appuyer les
nouveaux parents, Santé publique Ottawa met à leur disposition une vaste gamme de
cours prénatals, les programmes offerts variant de cours prénatals en ligne à de petits
groupes de grossesse destinés aux clients qui ne peuvent accéder aux services
d’éducation prénatale.
Santé publique Ottawa offre également du soutien prénatal et des mesures
d’intervention précoce aux parents aux prises avec des difficultés comme une maladie
mentale ou physique, des troubles du langage, la pauvreté ou l’abus. Ces programmes
de soutien sont offerts par des infirmières en santé publique, un travailleur social et des
visiteurs familiaux dans le cadre du programme Bébés en santé, enfants en santé.
Par ailleurs, Santé publique Ottawa est sérieusement engagée à promouvoir, protéger
et appuyer l’allaitement maternel. La décision d’allaiter est souvent prise avant la
conception ou dès les premiers stades de la grossesse. Santé publique Ottawa
collabore activement avec des partenaires communautaires pour promouvoir et
favoriser l’accès à des ressources sur l’allaitement dans le but de favoriser la
croissance et le développement sains des enfants.
Dans l’avenir, Santé publique Ottawa s’efforcera de sensibiliser les fournisseurs de
soins de santé et les adultes en âge de procréer à l’importance du poids maternel et
d’un gain de poids approprié pendant la grossesse. Santé publique Ottawa étendra par
ailleurs l’accès à ses groupes de grossesse aux familles aux prises avec des difficultés,
comme les nouveaux arrivants et les personnes sans domicile fixe. Pour continuer à
appuyer les mères qui allaitent, Santé publique Ottawa, le Programme régional des
soins à la mère et au nouveau-né de Champlain et d’autres fournisseurs de services
évalueront leurs expériences avec les services existants de soutien à l’allaitement afin
de mieux comprendre les problèmes qu’ils peuvent avoir observés en matière
d’allaitement.
Enfin, Santé publique Ottawa continuera de travailler de concert avec ses partenaires
pour aider les futurs parents à connaître de saines grossesses, des naissances
optimales et une transition sans heurt vers le rôle de parents afin de faire en sorte que
tous les enfants d’Ottawa commencent leur vie en santé.
BACKGROUND
This report is the first of a series of four reports on early childhood development, from
preconception up to a child’s first years at school. The purpose of the series is to
provide an overview of current programs and services for Ottawa families and
demonstrate the importance of investing in early childhood development to give all
children a healthy start in life.
In April of 2013, Ontario’s Chief Medical Officer of Health released Make No Little Plans:
Ontario’s Public Health Sector Strategic Plan. The plan identifies key areas of focus for
public health over the next three to five years and establishes five strategic goals – the
first: to optimize healthy human development by focusing on early childhood
development, including mental wellness and resiliency. The importance of early
childhood development forms the foundation of the Ontario Public Health Standards
(2008) family health pillar. It has also been highlighted in Ontario's Healthy Kids Panel
Report (2013), Ontario's Poverty Reduction Strategy (2013), Fair Society, Healthy
Lives: The Marmot Review (2010), and Pascal’s report entitled With our Best Future in
Mind: Implementing Early Learning in Ontario (2007).
Healthy development starts before a child is born. Healthy pregnancies lead to healthy
babies and children who are more likely to be ready for school and grow up to be
healthy adults.5 Early life experiences will affect how children develop cognitively,
socially and physically and will have lifelong effects on their health and well-being - from
obesity, heart disease and mental health, to educational achievement and
socioeconomic status. Risks early in life, including prenatal exposure to tobacco and
alcohol, living with family violence, and not having enough money to pay for nutritious
food, can result in a cascade of poor health outcomes. Some of these negative health
outcomes may not be apparent for decades.6 Early exposure to positive and protective
factors, however, can help a child grow to have a healthy and successful life. Examples
of protective factors include being breastfed, living in stable housing and having a
supportive relationship.
Both risk and protective factors are influenced by more than the lifestyle choices that
expecting parents make. They can be biological and/or environmental in nature and can
influence birth outcomes and parents’ ability to provide for their child. Inextricably linked
to these are the social determinants of health, which are the conditions in which people
are born, grow, live, work and are mostly responsible for health inequities. Health
inequities are the unnecessary differences in health experienced by certain population
groups.
Examining the social determinants of health can help us better understand challenges
that families in Ottawa may face. For instance, in Ottawa 12% of households are
considered low income.7 Of the residents who receive Ontario Works benefits, 38% are
children aged 0 to 17 years, with half being children aged 0 to 6 years.8 In terms of
education, 7% of Ottawa residents aged 25 to 64 have no certificate, diploma or
degree.9 Most residents in Ottawa speak English or French, however 11% speak
another language at home, with the most common being including Cantonese,
Mandarin, unspecified Chinese dialects, Arabic, Spanish, and Vietnamese.10 In addition,
almost 4% of mothers surveyed who delivered a baby in Ottawa in the past year did not
have a designated primary health care provider.11 These are all examples of how social
determinants of health can put some Ottawa families at greater risk.
Investing in early child development can help diminish the potential negative health
impacts of inequitable social determinants of health. Some economists agree that it is a
powerful investment, with returns over a child’s lifespan being many times the size of
the original investment.12 For example, every $2 invested in early childhood education
saves $7 in health, education and social costs later in life.13 In addition, in Ontario, low
birth weight and preterm babies account for a disproportionate percentage of health
care costs among newborns.14 An estimated $20 million is also spent annually on
untreated maternal depression in pregnancy.15
The goal for reproductive health in the Ontario Public Health Standards is "enabling
individuals and families to achieve optimal preconception health, experience a healthy
pregnancy, have the healthiest newborns(s) possible and be prepared for parenthood."
One of the best indicators for child development during this phase of the lifecycle is birth
outcomes, in particular birth weight.16 In Ottawa and Ontario, the rate of low birth weight
has been steady at 6% on average per year since 2008.17 The rate of small for
gestational age babies was 8% on average per year in Ottawa, which is statistically
significantly lower than the rate of 9% in Ontario (less Ottawa) during the same period.
These infants are at greater risk for infections, delayed motor and social development,
and learning disabilities. On the other hand, babies who are large for gestational age
are at increased risk of having birth complications, developing diabetes, and being
overweight or obese in later childhood. Twelve percent of babies in Ottawa are
classified as large for gestational age on a yearly basis since 2008, which is statistically
significantly higher than Ontario (less Ottawa) which has a rate of 10.4%.18
Maternal health before and during pregnancy has a significant impact on birth weight
and birth outcomes, and includes individual behaviours and maternal characteristics.
For example, maternal smoking, excessive gestational weight gain, substance abuse,
prenatal anxiety and depression, and maternal hypertension can all contribute to
negative birth outcomes. In 2013, 5% of women who gave birth in Ottawa reported
smoking during their pregnancy, and 3% reported using alcohol. In the same year, 16%
reported having mental health concerns, with anxiety, depression and a history of post-
partum depression being most common.19 Approximately 34% of women are overweight
or obese when they get pregnant and more than one-third of pregnant women exceed
the recommended weight gain during pregnancy in Ottawa.20
In order to support mothers and children to get the best possible healthy start, OPH
works with partners from various sectors to support parents as they prepare for and
make the life transition to having a child. A recent report by Growing up Great Ottawa
Child and Youth Initiative identifies baseline indicators of health for children and youth in
Ottawa, such as rates of low birth weight, exclusive breastfeeding for the first 6 months
of life, childhood injuries, school readiness, youth unemployment, and graduation from
high school.21 This initiative of over 80 organizations aims to set community targets that
guide collective efforts to improve programs and services for families across Ottawa.
OPH also works with health partners on the Champlain Maternal Newborn Regional
Program (CMNRP) to coordinate and improve perinatal care both in the community and
in the birthing centres in Ottawa and surrounding areas. Some programming is tailored
to particular populations, such as young single parents. OPH works with St. Mary's
Home, the Salvation Army Bethany Hope Centre, and the Youville Centre to provide
pre- and post-natal education, individual tobacco cessation, breastfeeding support and
group sessions to help teen and young adults care for and parent their babies.
DISCUSSION
Almost 10,000 babies are born every year in Ottawa.22 Given that not all pregnancies
are planned, OPH provides information on preconception health at workplaces and in
school settings to raise awareness of the importance of maternal and paternal health
behaviours among those of childbearing age. Eating nutritious food, including foods
high in folic acid, being physically active, following Canada’s Low Risk Alcohol Drinking
Guidelines and living smoke-free, as well as having healthy relationships and positive
mental health all contribute to healthier babies in our community.
For expecting parents, OPH provides a broad range of prenatal education options to
meet the different needs of expectant mothers and families in Ottawa. Online prenatal
classes are available with an option to speak directly with a public health nurse,
covering topics in both early and later pregnancy. Easily-accessible, small group
sessions are offered at libraries across Ottawa on a continuous basis. Public health
nurses focus on building skills and confidence in women and their birth partner around
‘Baby Basics’ – breastfeeding, caring for an infant and general parenting. Pregnancy
Circles, which are more informal gatherings, are offered to mothers that may not feel
comfortable with mainstream programming. Currently Pregnancy Circles are offered at
St. Mary’s Home, Salvation Army Bethany Hope Centre, Youville Centre Ottawa,
Wabano Centre for Aboriginal Health, and at several community health and resources
centres in the City.
As previously reported in the August 2012 Renewal of the Healthy Babies, Healthy
Children Program (ACS2012-OPH-CP-0001) report to the Board, OPH offers prenatal
support, information and early intervention to expectant parents experiencing
challenges related to physical illness, language barriers, mental health, low
socioeconomic status or abuse. These supports are offered by public health nurses, a
social worker and family visitors and are intended to help prepare families for the birth
and the transitions to parenting. OPH encourages partner agencies, such as primary
care physicians, the Children’s Aid Society, shelters and prenatal teachers to refer
prenatal families experiencing challenges to OPH.
Breastfeeding is one of the strongest protective factors for healthy growth and
development of children, and also provides numerous health benefits for mothers. The
decision to breastfeed is often made before conception or in the early stages of
pregnancy. As a Baby-Friendly Initiative (BFI) designated organization, OPH strives to
deliver excellent evidence-based services to promote, protect and support
breastfeeding (See: Baby-Friendly Initiative: Protecting, Promoting and Supporting
Breastfeeding). This includes a range of activities such as promoting a baby-friendly
environment to normalize breastfeeding and offering the Ottawa Breastfeeding Buddies
(OBB) Program. In OBB, experienced mothers are matched, often prenatally, with
families who would like support to breastfeed their infant. This telephone support
program is now available in 19 languages and served over 120 families in 2013. Many
recipients of the program become volunteers themselves as they view this service as
meaningful and valuable. Over three-quarters of mothers involved in the program in
2013 breastfed their babies as long as or longer than they had originally anticipated.
Future Programming
With growing concern around childhood obesity, there is emerging evidence that birth
weight predisposes a child to obesity. Babies born large for gestational age are at
increased risk for developing diabetes and being overweight in later childhood. To-be
mothers who are overweight themselves before pregnancy, or those who gain
excessive weight during pregnancy are more likely to have large for gestational age
babies, to develop gestational diabetes, high blood pressure and to have assisted
deliveries. OPH will raise awareness of the importance of maternal weight and
appropriate gestational weight gain with health care providers, and adults in their
childbearing years through educational and social media awareness approaches.
There is a significant drop in breastfeeding rates during the early post-partum period.
OPH will continue to support mothers’ breastfeeding and improve infant and family
health through a partnership with the Champlain Maternal Newborn Regional Program
(CMNRP). OPH, CMNRP, and other service providers will be assessing mothers to
understand their experiences with current breastfeeding support services. Preliminary
results are expected by the end of the year, and will inform service improvement plans
to help provide a seamless transition between hospital and community health services
around breastfeeding. A recent local survey found that many women did not anticipate
some of the challenges they encountered with breastfeeding, 23 so this assessment will
help ensure that new mothers are able to successfully initiate and sustain
breastfeeding.
OPH will be working with community partners to expand the number of Pregnancy
Circles from seven sites to ten sites. Pregnancy Circles will target clients who do not
usually access prenatal education services, such as low-income expectant parents,
newcomers and those with unstable housing. OPH will be partnering with additional
community health and resources centres, newcomer organizations, housing and social
service hubs, youth service providers, and shelters. Further, individual support through
the home visiting program will be strengthened by increasing prenatal referrals to the
program for those experiencing challenges such as mothers with mental health issues.
Healthy child development starts in preconception and is influenced by genetics, the
physical and social environments that surround the family, as well as by the choices that
parents are able to make. Together with existing and new partners, OPH will assist
parents in achieving healthy pregnancies, optimal birth outcomes and a positive
transition to parenting to help ensure all children in Ottawa receive a healthy start.
/RURAL IMPLICATIONS
There are no rural implications to this information report.
/LEGAL IMPLICATIONS
There are no legal impediments to receiving the information in this report.
RISK MANAGEMENT IMPLICATIONS
There are no risk management implications associated with this report
FINANCIAL IMPLICATIONS
There are no financial implications associated with this report.
ACCESSIBILITY IMPACTS
There are no accessibility impacts associated with this report.
TECHNOLOGY IMPLICATIONS
There are no technology implications associated with this report.
BOARD OF HEALTH PRIORITIES
This report support Board of Health priority to increase programming to support healthy
child development.
TERM OF COUNCIL PRIORITIES
This report supports the Term of Council priority to build Healthy and Caring
Communities.
DISPOSITION
OPH will continue to offer programs and services to families of reproductive age and
ensure that its policies support early childhood development.
1
Karoly L. Toward Standardization of Benefit-Cost Analyses of Early Childhood
Interventions. Arlington (VA): Rand 2008; 2008, as cited in the Ontario Ministry of
Health and Long-Term Care. Make No Little Plans: Ontario’s Public Health Sector
Strategic Plan. 2013.
2
High Birth Weight: Live births with a birth weight of 4500 g or more, expressed as a
percentage of all live births with known birth weight. Low Birth Weight: Live births less
than 2500 g, expressed as a percentage of all live births with known birth weight.
3
Karoly L. Toward Standardization of Benefit-Cost Analyses of Early Childhood
Interventions. Arlington (VA): Rand 2008; 2008, as cited in the Ontario Ministry of
Health and Long-Term Care. Make No Little Plans: Ontario’s Public Health Sector
Strategic Plan. 2013.
4
Poids de naissance élevé : Naissances vivantes dont le poids à la naissance est de 4
500 g ou plus, exprimé en tant que pourcentage de toutes les naissances vivantes dont
le poids à la naissance est connu. Faible poids de naissance : Naissances vivantes d'un
poids inférieur à 2 500 g, exprimé en tant que pourcentage de toutes les naissances
vivantes dont le poids à la naissance est connu.
5
Ontario Ministry of Health and Long-Term Care. Make No Little Plans: Ontario’s Public
Health Sector Strategic Plan. 2013
6
Irwin LG, Hertzman C, Siddiqi A. Early Child Development: A Powerful Equalizer.
Vancouver, BC: Human Early Learning Partnership (HELP). Commissioned by the
World Health Organization; 2007.
7
Statistics Canada. 2013. Ottawa, CV, Ontario (Code 3506008) (table). National
Household Survey (NHS) Profile. 2011 National Household Survey. Statistics Canada
Catalogue no. 99-004-XWE. Ottawa. Released September 11, 2013. [cited 2014 Jan
15]. Available from: http://www12.statcan.gc.ca/nhs-enm/2011/dppd/prof/index.cfm?Lang=E
8
Community and Social Services Department, City of Ottawa, 2012. Service Delivery
Model Technology database.
9
Statistics Canada. 2013. Ottawa, CV, Ontario (Code 3506008) (table). National
Household Survey (NHS) Profile. 2011 National Household Survey. Statistics Canada
Catalogue no. 99-004-XWE. Ottawa. Released September 11, 2013. [cited 2014 Jan
15]. Available from: http://www12.statcan.gc.ca/nhs-enm/2011/dppd/prof/index.cfm?Lang=E
10
Statistics Canada. 2013. Ottawa, CV, Ontario (Code 3506008) (table). National
Household Survey (NHS) Profile. 2011 National Household Survey. Statistics Canada
Catalogue no. 99-004-XWE. Ottawa. Released September 11, 2013. [cited 2014 Jan
15]. Available from: http://www12.statcan.gc.ca/nhs-enm/2011/dppd/prof/index.cfm?Lang=E
11
Integrated Services for Children Information System (ISCIS), Date Extracted: April 8,
2014.
12
Irwin LG, Hertzman C, Siddiqi A. Early Child Development: A Powerful Equalizer.
Vancouver, BC: Human Early Learning Partnership (HELP). Commissioned by the
World Health Organization; 2007.
13
Karoly L. Toward Standardization of Benefit-Cost Analyses of Early Childhood
Interventions. Arlington (VA): Rand 2008; 2008, as cited in the Ontario Ministry of
Health and Long-Term Care. Make No Little Plans: Ontario’s Public Health Sector
Strategic Plan. 2013.
14
Ohlsson A, Shah P. Determinants and prevention of low birth weight: a synopsis of
the evidence. AB: Institute of Health Economics; 2008, as cited in the Ontario Ministry of
Health Promotion. Reproductive Health Guidance Document. 2010.
15
O’Brien L, Laporte A, Gideon K. Estimating the economic costs of antidepressant
discontinuation during pregnancy. Can J Psychiatry 2009;54(6):399–408, as cited in the
Ontario Ministry of Health Promotion. Reproductive Health Guidance Document. 2010.
16
Canadian Institute for Health Information. Too early, too small: a profile of small
babies across Canada. Ottawa, ON; 2009, as cited in the Ontario Ministry of Health
Promotion. Reproductive Health Guidance Document. 2010.
17
Inpatient Discharges 2008-2012 calendar years, Ontario Ministry of Health and LongTerm Care, IntelliHEALTH ONTARIO, Date Extracted: January 23, 2014
18
Inpatient Discharges 2008-2012 calendar years, Ontario Ministry of Health and LongTerm Care, IntelliHEALTH ONTARIO, Date Extracted: January 23, 2014
19
BORN Information System 2013, Date Extracted: January 17, 2014
20
BORN Information System 2013, Date Extracted: April 16, 2014
21
Ottawa Child & Youth Initiative Growing Up Great. Charting Outcomes: Community
Actions for Healthy Development of Children and Youth in Ottawa. Ottawa, ON; 2014.
22
Inpatient Discharges 2008-2012 calendar years, Ontario Ministry of Health and LongTerm Care, IntelliHEALTH ONTARIO, Date Extracted: January 23, 2014
23
Milroy E, Patel H, White C, Zelikovitz K, Adams E & Villeneuve P. An examination of
the factors influencing breastfeeding initiation and duration in a survey of Ottawa
mothers. HLTH 5500 Capstone Research Project: Final Report. Carleton University,
April 3, 2014.