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