Aboriginal Prenatal Wellness Program (APWP) By Sherri Di Lallo RN, BScN
Abstract 2010
In 2007, statistics in the last six years showed all the women in Central Zone Alberta who delivered at Wetaskiwin Hospital and Health Centre 16.5% received little or no prenatal care. From those statistics 82% of women who received little or no prenatal care were from Hobbema (DTHR, 2007).
In 2005, the Aboriginal Prenatal Wellness Program (APWP), a prenatal clinic developed to help Aboriginal women and families access culturally appropriate and integrated prenatal care, was started to better prepare women for delivering healthy babies.A multidisciplinary team approach provides prenatal health information that is consistent, assessments that are ongoing, and support through community agencies. The nursing implications include recognition of the value of the Medicine Wheel in its cultural context.The teachings of the ‘Medicine Wheel’ are implemented by being culturally aware and providing opportunities to care for the mother and family in a manner that addresses mental, emotional, physical and spiritual health and wellbeing. Furthermore, partnerships with the expectant mother, father, family and the community were developed.
Quote: I couldn’t enjoy all the benefits of the program because I was already late in mythird trimester
When I began working on the obstetrics ward in the Wetaskiwin, Alberta hospital, I became concerned that Aboriginal women from the neighbouring reserves in the community of Hobbema were showing up with little or no prenatal care before delivering their babies. Statistically, the number was as high as 82% (DTHR, 2007). There was a large disconnect between the nursing staff and these women due to cultural differences and a lack of understanding from both groups.
As a result, I made prenatal care for Aboriginal women my focus, incorporating health promotion and wellness and building working partnerships with Aboriginal communities and Western Medicine. To this end, in 2005, The Aboriginal Prenatal Wellness Program (APWP) was created to target the Aboriginal women in the area who were not accessing the traditional system for prenatal care. Because of factors like lack of transportation, childcare, a fear of being judged for lifestyle choices, and fear of the health care system, these women often would have little or no prenatal care but were at an elevated risk for problem deliveries.
Statistics indicate that 19.5% of woman from DTHR received little or no prenatal care but that has decreased by 6% by 2007, may be largely due to the success of the APWP (DTHR, 2007). The APWP provides a prenatal clinic that is holistic in its care and is client centered; designed to empower the expectant mother, father and their family. Culturally appropriate and integrated into an existing health care clinic, APWP combines the components of prenatal health, assessment and support and includes doctors and nurses liaising with community agencies, life support counselors, and Elders.
This balance of care reflects the Medicine Wheel in providing the mental, emotional, spiritual and physical components of wellness for holistic health. As the Report of the Royal Commission on Aboriginal People expresses, “Aboriginal women who are pregnant need culture-based prenatal outreach and support programs, designed to address their particular situation and vulnerabilities” (2006, p. 6). The APWP is a culturally relevant clinic that addresses the issues facing this particular group of women.
Quote: “What I like the most was the fruit and updates of my pregnancy”
Team Approach and the Delivery of Prenatal Care
A multidisciplinary team including doctors, nurses, support staff at the clinic, and workers from Hobbema and Wetaskiwin community agencies work together to provide consistent and coordinated health care. The delivery of APWP is creative and unique. The doctors and nurses help inform mothers and fathers about choices in having a healthy pregnancy by providing ongoing information and assessments and opportunities for them to ask questions about the health of their baby and themselves. Obstetrical nurses are the main contact for the women and provide the majority of primary health care.
When a woman comes to the clinic, she is directed to the Obstetrical nurse who starts a chart with the woman’s history, completes urine dip stick test, and does a complete physical exam. The woman is offered fruit, cookies, and juice to provide a companionate and caring environment as well as offering nourishment. They are then taken to an assessment room where a patient history is completed along with emotional, mental, and spiritual assessments. The nurses will also complete a social well-being and behavior risk assessment. These assessments are used as indicators for further coordination with on and off-site counselors. If the patient, in partnership with the nurse, feels that a counselor is needed, the nurse will make the introduction thereby bridging the gap in the process where fear will often deter a woman from seeking that assistance.
Next, the nurse completes the physical exam for the patient including a woman’s wellness exam and blood work when necessary. Then the patient gets to hear her baby’s heart through the Doppler, often for the first time. At the end of the appointment, the physician will review all the results and speak with the patient regarding her care and give her the opportunity to ask questions.
The women come to see the prenatal nurses because they trust them, feel more comfortable with a woman doing the physical examinations, and believe in their genuine care and concern for their wellbeing because of an ongoing relationship with the team. The team at the prenatal clinic is also imperative to the organization and delivery of information and ongoing support to the expectant mothers. Both pre and post natal care focuses on the woman’s overall health and offers support to her family as well. Children are allowed to attend appointments with the mother and, through an agreement with the Health Canada medical transport, they are brought to the clinic free of charge.
Furthermore a large number of obstetrical nurses that work at the Wetaskiwin Hospital and Care Centre also work with Aboriginal Prenatal Wellness Program, which is located in Wetaskiwin in a local doctor’s office. The expectant parents come to the Wetaskiwin Hospital and Care Centre knowing what to expect and seeing a familiar face helps the labour and delivery process go a lot better mentally and emotionally. They are less likely to be fearful of stigma and more open to the process. The program has helped diminish some of the barriers by being perceptive to cultural awareness and communication.
The agencies in Hobbema fully support the program and believe programs like this are needed to empower moms and dads to access prenatal care. This partnership contributes greatly to the success of the APWP. Many of the mothers are clients of the Samson Healthy Families and may also receive support from the FASD mentorship program. There is also opportunity for the mothers to understand the importance of healthy pregnancy through a cultural perspective through the teachings given by the Elder.The recognition of those natural inherent assets and connecting such to the clinic allow the mother and family to receive holistic and comprehensive care that is meaningful to them.
Quote: “Thank-you for taking your time to make me feel comfortable day by day”
History
Hobbema consists of four First Nation bands with a total population of 13,784 people and is located 15-45 minutes south of Wetaskiwin in Central Alberta. Though close in physical proximity, the cultural barriers between the communities are vast.
To understand the underlying causes of the barriers of prenatal care a person needs to understand the history. Hobbema’s First Nations people experienced mental, emotional, physical, and sexual abuse while attending residential schools in the 1950’s and early 60’s. These children were stripped of their culture, language, and teachers, therefore unable to go through the rites of passage. When the residential school children became adults they passed on their abuse or emotional damage they endured in residential school onto their own children and families, the cycle of abuse.
How this affects childbearing? If someone is brought up in an environment of abuse and neglect, until someone stops that cycle of abuse, prenatal care, along with other health issues are not a priority. Some expectant moms are just thinking about surviving another day. Not living but surviving. They may be thinking about how to put food on the table for their children, care for a sick parent or grandparent, or even finding a place to live for themselves and their unborn child. They are reluctant to approach the Eurocentric health care system as fear of stigma and lack of cultural respect have also been multi-generational issues.
It is imperative that the multidisciplinary team understands the past to promote strategies with the community to improve health and wellness for the future. First Nations women under 20 years of age are 4.7 times more likely to give birth than women of the same age group in the general population. In 1999/2000, First Nations women had an average of 2.5 children, compared to 1.6 children per woman in the general population (Aboriginal Healing Foundation, 2003).
Neonatal and infant health is affected by the socioeconomic conditions and health choices of expectant women and new mothers (Report of the Royal Commission Report, 2006). A prenatal survey in 2004 done through Samson Healthy Families, one of the main partners for informing target women for the clinic, showed that 48% of the expectant mothers missed prenatal appointments mainly because of a lack of transportation and child care. The Report also indicates stillbirth and peri-natal death rates among Aboriginals are double the Canadian average. “Beyond the risk of premature mortality, long term human health is influenced by what happens in the womb and in the first months and years of life. Health researchers are only beginning to understand how subtle and far reaching the effects of pre- and postnatal health can be” (2006, p. 2).
According to Annette Cutknife, the FASD Program Coordinator with Samson Healthy Families, “there is a concern with young women between the ages of 16-18 years drinking throughout pregnancy” and she believes that the APWP is a preventive screen for FASD and Dual Dependency. In addition, Aboriginal women have been identified by Wenman, Joffres, Tataryn and the Edmonton Perinatal Infections Group as having poorer pregnancy outcomes when compared to other Canadian women. “We found a higher prevalence of smoking, poor nutrition, low income, a previous premature infant and bacterial vaginosis among Aboriginal women than among non-Aboriginal women” (2004, p. 588).
Quote: “Most of the nurses took the time to explain everything in words I understood”
Discussion
In the course of the program funded by Alberta Health Services (Alberta Health and Wellness) from November 2005 to February 2009 there were 281 participants. Statistics showed in 2006, 5% of women were high risk and in 2007, 7% were high risk. Expectant moms that use the clinic are being assessed earlier and diagnosed earlier with a high risk pregnancy therefore provided with close monitoring for the rest of the pregnancy. The Aboriginal Prenatal Wellness Program statistics revealed that of the women attending the program, 14 % are under the age of 17 years, 58% are between the ages of 18 to 25 years and 28% are over the age of 26.
David Thompson Health Authority (DTHR) statistics in the last six years showed all the women in Central Zone Alberta who delivered at Wetaskiwin Hospital and Health Centre 16.5% received little or no prenatal care. From those statistics 13.5% of women who received little or no prenatal care were from Hobbema where as 3% were from the rest of Central Zone (DTHR, 2007).
Of all the deliveries in Wetaskiwin Hospital and Health Centre in the last 6 years; the percentage of women having limited or no prenatal care has been dropping. In 2002 indicated 19.5% of women had limited or no prenatal care but in 2007 the number dropped to 13.5%. Therefore there was a 6% drop in women not showing up for prenatal care perhaps to the unique access to prenatal care for Aboriginal women through the Aboriginal Prenatal Wellness Clinic.
The women felt the process of delivery of care was more efficient and supportive to their needs through education and what to expect throughout their pregnancy. They felt the team provided enhanced and efficient patient care. They didn’t feel rushed, they had more time to talk about their concerns and they were able to listen to the information being provided. The moms and fathers felt seeing the doctor at the end of the visit was valuable in the continuum of care by asking about health concerns that may have come up when talking to the nurses.
Quote: “The program is good and I wish they brought it earlier with my other kids”
Evidence of returning clientele is supported by APWP statistics, which indicates a 3% increase of women showing up as soon as they suspect they are pregnant. In addition APWP statistics illustrate when women were asked who they preferred to see during their prenatal care, 54% of women stated they would prefer to see both a doctor and nurse. Hence by having a nurse available for prenatal care supplemented the services already provided by the physician.
As the Royal Commission Report indicates “the desire for a healthy child gives all pregnant women a powerful motivation to stop using alcohol and drugs” (2006 p. 6). APWP statistics show that 44% of patients stated they quit drinking and using drugs once they found out they were pregnant while 39% decreased their smoking and 16% quit smoking. The women are aware of healthy behaviors and as a multidisciplinary team, we need to recognize and support these healthy behaviors (Lewallen, 2004).
In addition the same approach was initiated with breastfeeding. Women were asked early in pregnancy about breastfeeding therefore they have more time to think about breastfeeding; as their due date gets closer the nurses and clients continue the discussion of breastfeeding. APWP statistics showed that 50 % of women wanted to breastfeed longer than 6 months and overall 98% planned on breastfeeding. The obstetrical nurses found more women attempted to breastfeed in hospital especially the first time moms.
Of the women who have experienced the prenatal clinic, 97% of women stated they would come back to the program with future pregnancies and 98% stated the program met their needs. In addition 98% stated they would recommend the program to family and friends. 23% of the women would not access prenatal care if it wasn’t for the prenatal clinic whereas 47% of the women stated that the prenatal clinic helped them access prenatal care earlier. When expectant mothers asked if they preferred appointments or walk in clinic, 60% of women preferred appointments while 35.5% preferred walk-in. Overall, providing a walk in clinic helped 35.5% of women access prenatal care more regularly than if only appointment was available.
Quote: “A genuinely caring facility where my baby and I are not just another number”
Nursing Implications
Major implications for nursing practice include the development of cultural awareness for the nurses and communication strategies to help the expectant mothers and fathers feel safe and supported about prenatal care. The increased access to routine prenatal care, which in turn positively influences the birth experience for the mother, father and their family, makes for a more emotionally and physically positive experience. The partnership with community agencies is imperative as their expertise and resources bridges the community, prenatal clinic, and hospital and by introducing the women to these services directly, the women are more likely to use them. Using a multidisciplinary team holistic approach has influenced combining traditional and modern practices not only with respect to birthing but for other health incentives as well.
According to the Royal Commissions Report, “in the case of childbirth, many Aboriginal women are arguing for a combination of traditional and modern practices” (2006, p. 9). The APWP makes sense since women will receive the care they need and decrease the risk for further interventions. Women that are moderate to high risk are monitored more closely supplementing the services provided by the physicians. Furthermore this model of care allows registered nurses to use their full scope of skills and expertise in providing care to the expectant mothers.The health care team, in partnership with community agencies, educates moms and dads regarding high-risk behaviors (i.e. Sexual Transmitted Infections, FASD and or Dual Dependency) so they can make healthier choices for their baby and themselves.
Nurses and doctors also need to be aware of their spiritual side when working with Aboriginal women. Aboriginal women, men and their families may use some form of spirituality to cope with the stress of birthing. Our health care team helps support spiritual beliefs during this time by providing access to Elders, prayers, and Sweetgrass ceremonies during the laboring experience.
The message of getting earlier prenatal is being supported in the community as women, agencies and health care providers work together through the continuum of care. The Aboriginal Prenatal Wellness Program is a unique model to empower mothers, fathers and families to improve their knowledge of pregnancy and childbirth and provide valuable support from community agencies, counselors, Elders and all health care providers.
Quote:
“I am glad there is a program like this for the communities and for future mothers” and nice to see people work together as a team”
***Note:
The Aboriginal Prenatal Wellness Program’s concept has been expanded to the office of an Obstetrician/Gynecologist in Wetaskiwin, Alberta. The model has been implemented into the Aboriginal Women’s Wellness Clinic which provides health promotion and screening on prenatal care, sexually transmitted infections, contraception and gynecological services. Furthermore community development and collaboration are imperative in the promotion of health for Aboriginal women.
Great Thanks and Gratitude goes to the team that supported the Aboriginal Prenatal Wellness Program:
Our Creator
Alberta Health Services ( Alberta Health and Wellness)
Health Canada: Transportation and Public Health
Samson Health Families and Brighter Futures
David Thompson Health Region
Wetaskiwin Family Medical Practice
Wetaskiwin Health Unit
Wetaskiwin Hospital and Care Centre
Directions for Wellness Inc.
References
Aboriginal Healing Foundation, Annual Report 2003; and First Nations Regional Longitudinal Health Survey 2002–03
Aboriginal Prenatal Wellness Program. (2009). Aboriginal Prenatal Wellness Program Statistics from Questionnaires.
PERSPECTIVES
