PERINATAL SERVICES FOR VULNERABLE FAMILIES IN BELGIUM (FRENCH & GERMAN SPEAKING PARTS)
Perrine Humblet, Research Center Social Approches to Health, RC-SATH,ULB, Brussels
TFIEY meeting 3, Lisbon, January 20-22 2014 1
The research context
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Fondation Roi Baudouin (KBF) 2013:– No large scale survey on perinatal services for vulnerable
families– Call for tender:
• French & german speaking partsFrench & german speaking parts• Dutch speaking (Flanders)
RC-SATH (ULB):Public health perspective• Coverage rates• Services system• Equity in access to high quality services
Team: A Cremers, A Labat, M Sow, P Humblet
Methods
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1. Definition – ‘perinatal’ (cf. WHO ICD10: 22 weeks of gestation – 7 days
after birth) KBF surveyKBF survey: psycho-social perspective: start of pregnancy to at least 1 year of child
2. No previous knowledge on the whole system whole system offering perinatalperinatal support /service inductive
Only a part of it well known : ANC + well-baby clinics run by Birth and Childhood Office
(ONE) /Children and Family Service)
Other services?
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Survey without prior definition but according functions Sample: identification through health promotion local settings,
internet screening, services federations, ‘snowball’ method screening questionnaire for indirect identification
1- pregnant women, young parents, young children as users? 2 – some or all vulnerable families? 3 - specific project?
questionnaire survey, close-ended + open-ended questions Final discussion groups with professionals – ‘group analysis
method (réseau MAG)’, 2 sessions devoted to 3 issues: 1.1.Users-professionals asymmetric relationshipUsers-professionals asymmetric relationship2.2.Come-structure/go-structuresCome-structure/go-structures3.3.Gaps in the sectorGaps in the sector
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3. Theoretical framework– social determinants of wellbeing/health inequity (WHO)
• structural drivers: economic arrangements, distribution of power, gender equity, policy frameworks and the values of society unequal distribution of the conditions in which people are born, grow, live, work wellbeing/health inequity
– Bronfenbrenner’s ecological theory • person–process–context–time
4. Objectives – Results on : What? - Who? - How? - Where?– No specific objectives on parent engagement– Recommendations
Some results
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Who? Two main categories1.ONE/DKF integrated medical/social clinics
– Birth and Childhood Office - public interest organization (parastatal)
– main mission: (now) • child's global health within his family and his social environment
•outside ONE/DKF: expanded scope of perinatal services for vulnerable families
1. Services initiated following a particular development or event
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1. Integrated medical/social clinics ONE/DKF– Universal free access with additional support at home
when needed (proportionate universalism)• Services: ANC, WBC + ‘liaison’ social worker in all maternity
units• individual (preventive medicine, social work) + collective health
promotion activities• (recently) cross-cutting task of supporting parents according
local needs
– Coverage:- ANC : average of 28% all births (but more important in 2
regions)- WBC (0-6 y):
1. systematic or regular use during 1st year: 53,5% all resident children in Walloon Region, 63,5% in Brussels Region
2. no use: 27,4 % Walloon Region, 21,7% Brussels Region
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Indicator of social needs : prevalence of low birth weight
socioeconomic gradients in birth weight geographical inequality
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ANC
WBC
Rural communes in white : mobile WBC
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2. ‘expanded scope of perinatal services ’ for vulnerable families outside ONE/DKF
What services?• variety of services responded to local families/children’s demand/need
• social and health ‘public services’ (public social welfare services, drop-in centres, medical centres, family planning centres, mental health services…)
• non-profit associations
• various social policies: childhood, family, social welfare, youth protection, youth support, culture…
How?o universal services (come-structure)
o Ex: centers for parents and young children together, Drop in units
o targeted services (go-structure) for highly vulnerable families, only home-based support or including it o Ex: drug addiction services for pregnant women & young parents
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How? the child at the heart
• as direct subject of the activity– psychomotor, child socialisation and health monitoring activities
• indirect beneficiary of an action aimed at his/her parents– material assistance for parents, information/contacts with professionals,
parent discussion groups
• parent-child bond as the focus, with the work involving both the child and parent
– parent-child activities, psychosocial support in pregnancy
individual level early parent-child bond, transfer of knowledge, supporting parents,
development of confidence, early-learning activities for childrencollective level
combating social isolation: child’s day , barters meetings, exchange of experiences, awareness about literacy, and so
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Objectives ? Drivers declared to be targeted
- psychosocial determinants psychosocial determinants (social support, social bond, social capital)
- behavioural determinants behavioural determinants (conduct and way of life; beliefs, knowledge, attitudes)
- socioeconomic determinants (status, resources and living conditions)
Model of action: To reinforce positive and protective health drivers >>> reduction of
risk factors
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Workers ? Staff
bachelors or masters in social, psychological and medical areas multidisciplinary teams as a rule investing time in + agreeing on the value of networking
between professionals and between institutions
Accessibility?– Primary access ( first contact)
• Language problems• ANC ONE: free but geographical inequalities • WBC ONE: free but opening hours not satisfactory• improve communication about /within services
– 2ary access: practices making the service an opportunity fitted to vulnerable families, service desirable?
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users-professionals asymmetric relationshipusers-professionals asymmetric relationship?
asymmetric relationship perception of control, stigmatization (and its consequences: avoidance, fear…), judgmental attitudes
= Issue proposed and discussed with the professionals
Issue much acknowledged by services with home visits Reflexivity on practices
Less acknowledged by ‘come-structures• centers for parents and young children together (specialized
‘come-structures’)• struggle to reach the most vulnerable parents
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1. Recommended practices for perinatalityo If demand : start with the demand for help
‒ DKF: financial prenatal fund‒ start support during the prenatal period,
preferably in ANC - general universal services‒ entry point of all families, no stigmatisation‒ If needed ‘reinforced’, additional home visit by
ONE social worker and more targeted service‒ ‘transmitting professional’ – trusted by family
‒ focus on concern for the well-being of the unborn child ‒ hopes and expectations represent a positive lever
for the parents + no label to parenting
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‒ adopt participative and co-educational approach‒ parents as full actors, transparency, shared
framework for relationships, no action behind their backs
‒ innovate practices to reach all families, all parents ‒ Ex: services inappropriate to males doesn’t help fathers
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2. Importance to ensuring continuity of support – continuity builds trust in support
• vulnerable families characterized by previous experiences of multiple relationship breakdowns
– Continuity : universal services + targeted • Role of transmitting professional
3. Holistic and multidisciplinary care– Take account of all dimensions
• families’networks and environment (home + neighbourhood)• contextual and cultural factors
– multidisciplinary collaboration • not easy ! medical/paramedical professionals and
psychologists'own paradigms
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4. Networking• Can inform on operational logics of other professionals
‘formative networking’• avoids duplication of work
– families must be informed about networking
• facilitate holistic care• source of high job satisfaction
conclusion
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= onset of perinatal bottom – up system BUT– Lack of a specific term used to name it
• lack of recognition- ‘oneness’ of the pre- and postnatal periods = lack of conceptual understanding
• recognition difficulties, training problems, lack of funding (which policy?), lack of evaluation– precarious working conditions of professionals to support vulnerable
families
– Lack of integration of proportionate universal system ONE• work organised according the services and not the perinatal
process no continuity work & workers ANC to WBC Outside ONE
– 1/3 isolated– 2/3 connected to universal services (ex: ONE) or networking