Prenatal Care through the eyes of Canadian aboriginal Women

Transcription

1 Prenatal Care through the eyes of Canadian aboriginal Women Sherri Di LaLLo

2 The Aboriginal Prenatal Wellness Program (APWP) in Wetaskiwin, Alberta, Canada, is a culturally safe program that provides clientcentered prenatal care that is designed to empower women, families and communities. The APWP was created in 2005 to serve Aboriginal women who weren t accessing the traditional system for prenatal care.

3 Because of barriers to health care, such as lack of transportation, lack of child care, fear of being judged for lifestyle choices and fear of the health care system due to historical implications, Aboriginal women often would have little or no prenatal care, putting them at increased risk for negative health outcomes (David Thompson Health Region [DTHR], 2008a). The APWP is based on a holistic care model that coincides with the teachings of the Medicine Wheel, incorporating mental, emotional, spiritual and physical wellness through health assessment, education and support (National Aboriginal Health Organization [NAHO], 2006). Services provided are on a continuum of care and involve community agencies, health professionals, social workers life support counselor and Aboriginal community Elders. Health care providers working for the program are trained and educated on cultural traditions and made aware of historical events, such as residential schools, that have affected Aboriginal women s access to care. The online report of the Royal Commission on Aboriginal Peoples (2006) stated that, Aboriginal women who are pregnant need culturebased prenatal outreach and support programs, designed to address their particular situation and vulnerabilities. Cultural-based traditional practices include supporting an Elder s role in counseling a pregnant woman. When a woman has pregnancy confirmed, she is offered to meet with the Elder for personalized one-on-one education that ties spiritual beliefs with the foundation of prenatal education. The Elder is also involved in group teaching of prenatal education at the prenatal clinic, prenatal classes or conferences. Elders teach the role of the creator in conception, as well as the valuing of life and stepping stones ceremony. They encourage and support participation in prenatal assessments/care and provide teachings on the blessing of motherhood. Background The four Maskwacis First Nations of Hobbema border Wetaskiwin and Ponoka Counties in Central Alberta and have a total population of 13,784 people. Though the communities are close in physical proximity, the cultural barriers that exist between the communities are vast. Aboriginal women often don t access prenatal health services due to negative experiences in the mainstream health care system. Between 2002 and 2007, 16.5 percent of all women in Central Alberta who delivered at Wetaskiwin Hospital and Care Centre had received little or no prenatal care prior to their delivery. Of those, 82 percent were from the Maskwacis area (DTHR, 2008a). A prenatal survey done in November 2004 Sherri Di Lallo, MN, RN, is a faculty lecturer at the University of Alberta in Edmonton, Alberta, Canada, vice president of the Aboriginal Nurses Association of Canada, and a former coordinator of the Aboriginal Women s Wellness Program and Women s Wellness Clinic. The author reports no conflicts of interest or relevant financial relationships. Address correspondence to: sherri.dilallo7@gmail.com. found that 48 percent of the expectant mothers missed prenatal appointments, mainly due to a lack of transportation and child care (Hendriks, 2004). Cultural Safety Cultural safety goes one step further than cultural competence by understanding the limitations of cultural competence, which focuses on the skills, knowledge and attitude of practitioners (Indigenous Physicians Association of Canada and Association of Faculties of Medicine of Canada [IPAC-AFMC], 2009, p. 9), but understands that promoting a partnership role in an individual s care is advantageous in helping support health and wellness. The key to practicing cultural safety is selfreflection and building trustful and respectful relationships (IPAC-AFMC, 2009). Further, cultural safety is being aware that one has power over the woman and that there are power discrepancies in health care delivery. Providing Culturally Safe Care To address solutions for cultural safety, nurses must analyze the problem and identify causes. By assessing cultural biases, health disparities, the history of residential schools and the benefits of culturally safe prenatal practices, nurses and health care programs can create an emotionally healthy environment for their patients. Assess Cultural Biases The first step in understanding cultural safety is seeing practice as a life-long learning process of cultural awareness, sensitivities, knowledge and skills. This can include valuing cultural diversity, implementing cultural self-assessments, being aware of the natural interactions of cultural dynamics, having knowledge of culture within organizations and modifying services based on the understanding of cultural safety (Aboriginal Nurses Association of Canada [ANAC], 2009; IPAC-AFMC, 2009).To understand the causes of cultural insensitivity, we must each examine our own biases. Being aware of how we each bring our own culture and beliefs to the health care relationship help create an environment of respect for the cultural differences (NAHO, 2008). Abstract: The Aboriginal Prenatal Wellness Program (APWP) in Canada represents a culturally safe approach to prenatal care. By understanding the history of colonization and residential schools and how this history has contributed to health disparities, a multidisciplinary team provides culturally competent and integrated prenatal care to Aboriginal women and their families. This article describes the APWP and discusses how increased participation in health care by historically marginalized populations can lead to better maternal and neonatal health outcomes. DOI: / X Keywords: Aboriginal women cultural competence maternal health prenatal care 40 Nursing for Women s Health Volume 18 Issue 1

4 Understand Health Disparities To provide culturally safe care, nurses and other clinicians must understand why there are health disparities within Aboriginal communities. Socioeconomic marginalization, along with the poor health status of many Aboriginal women has been researched and well-illustrated (NAHO, 2008). Moreover, the severe impacts of many of the diseases experienced by individuals living on-reserve or in isolated communities reveal a serious lack of access to health services. The direction for health must be addressed through a social determinants approach, since the determinants are interconnected (NAHO, 2008). Keeping that in mind, nurses working with Aboriginal women and their communities must address these barriers by making information sharing, partnerships and collaboration the key. Understand Cultural History Aboriginal people are haunted by memories of residential schools and of being forced into colonization. These schools were started and funded through the Canadian government s Department of Indian Affairs. Aboriginal children were taken from their homes to boarding schools where ties to their families were completely cut off and where horrible abuses often occurred. The idea was to kill the Indian in the child and to transform Aboriginal children from savages into civilized members of the Canadian society (Kuran, 2000, para. 3; Truth and Reconciliation Commission of Canada, 2012). Multigenerational residential school attendance was the key to PraCtiCing Cultural safety is self-reflection and building trustful and respectful relationships common, and the schools created an environment of distrust between Aboriginal and non-aboriginal populations that is still being passed on to the next generation today. Many of the community Elders were students in the residential schools and their stories are now being told firsthand. The immediacy of the history is being reflected in the lack of participation of the population in any institutional environment, including health care. Therefore, it s imperative that any health care provider working with an Aboriginal population understand the effects of the schools on the population and promote effective strategies for cultural safety within the organization (ANAC, 2009; IPAC-AFMC, 2009). Understanding the cycle of abuse experienced by Aboriginal people educates health care providers about the health disparities within that community and addresses attitudinal barriers include racism and prejudice (Smylie, 2001, p. 2). Many Maskwacis Cree are descendants of residential school February March 2014 Nursing for Women s Health 41

5 a team of nurses, PhysiCians, support staff and Workers from four local maskwacis nations and nearby Community agencies Work together to Provide Consistent and Coordinated health Care survivors, and many of those survivors are alive today and still have mistrust of western systems, seen most often in the lack of attendance in schools and accessing health care. Because of the animosity stemming from residential schools, generational mistrust of western systems has occurred. Often, health care workers in bordering communities don t understand and aren t sympathetic to these ongoing issues. The Health Council of Canada found that Aboriginal people feel discriminated against, isolated and judged when accessing the traditional health care system (2011). Problems addressed by the apwp This mistrust and lack of prenatal care has led to concerning health statistics (see Boxes 1, 2, and 3), which are reflected in the high numbers of Wetaskiwin births versus the Alberta average. The health of the infants born in Wetaskiwin is also of concern. The majority of infants born with concerning antenatal risk scores are First Nations. As well, a high number of women arrive at the hospital with little or no prenatal care, also the majority being First Nations. Aboriginal women attending the APWP have provided many examples of culturally insensitive care they had received before. For example, an Aboriginal woman showed up at the hospital in labor. She had no clothes or supplies for her baby. The health care provider criticized her for showing up with no supplies without realizing that First Nation cultural belief is not to buy anything for a baby until he or she is born. The woman felt unsupported and embarrassed. Another APWP participant had addictions issues. She had experienced negativity and felt judged when she went to a physician seeking help for her baby after abusing drugs. The physician s facial expression showed shock and disbelief when she saw the needle track marks on the woman s arm. In an abrupt and angry tone she stated, You can t be using drugs while you re pregnant. The woman felt shame and guilt and never went back for prenatal care. Fortunately, health care providers working in the APWP understand Aboriginal women s traditional practices and can help them feel more comfortable in a culturally safe environment. They are also trained to be sensitive to issues, although not specific to this population, that would prevent pregnant women from accessing prenatal care. a Team approach A team of nurses, physicians, support staff and workers from local four Maskwacis Nations and nearby community agencies box 1 aboriginal MaTernaL ChiLD health indicators Health Indicators Wetaskiwin County Alberta Fertility rate 74.8% 53.1% Infant mortality rate 6.6% 6.2% Teen birth rate (per 1,000 women 15 to 19 years of age) 65.6% 18.9% Smoking during pregnancy 50.5% (72% Maskwacis) 18% Drinking during pregnancy 8% 4% Sources: Alberta Health, Primary Health Care Division (2013), DTHR (2005), Hendriks (2004). 42 Nursing for Women s Health Volume 18 Issue 1

6 work together to provide consistent and coordinated health care. Obstetric nurses are the main contact and provide the majority of primary care. First visits usually last 30 to 45 minutes and subsequent visits are approximately 20 minutes. When a woman comes to the walk-in clinic located in a doctor s office, she is directed to the obstetric nurse who starts a chart with the woman s history, completes urine and blood tests and does a complete physical exam. The woman is offered fruit, cookies and juice. A holistic patient history is completed with medical, emotional, mental and spiritual assessments. These assessments are used as indicators for further coordination with on- and off-site social supports. If it s agreed 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. Then, the woman gets to hear her baby s heart through the Doppler. For some multigravida patients, this is the first time ever hearing a heartbeat. At the end of the appointment, the physician will review all the results and speak with the woman regarding her care and give her the opportunity to ask questions. Women who are at moderate to high risk are monitored more closely by nurses, thus supplementing the services provided by physicians. This model of care allows registered nurses to use their full scope of skills and expertise in providing care to pregnant women. Women often come to see the prenatal nurse because they trust her, feel more comfortable with a woman doing the physical examinations and believe in her genuine care and concern for their well-being because of an ongoing relationship with the team. The team at the prenatal clinic is imperative to the organization and delivery of information and ongoing support to the pregnant women. Both pre- and postnatal care focuses on women s overall health and offers support to their families, as well. Children are welcome to attend appointments with their mothers and, through an agreement with the Hobbema medical transport, women and children are brought to the clinic free of charge, thus addressing the barrier of lack of transportation. Several obstetric nurses who work at the Wetaskiwin Hospital also work with the APWP. Because of this, laboring women and their families arrive at the hospital prepared rather than fearful, and seeing a familiar face helps facilitate the labor and birth process. The APWP has helped diminish Aboriginal women s fears of being judged, discriminated against or isolated and participation in the APWP is on the rise (APWP, 2009). evaluating the Program The prenatal clinic was partnered with a variety of stakeholders that promoted the program through their agency, such as Brighter Futures, in each of the four First Nations communities, four doctor s offices and two public health centers. Participants were mostly First Nation pregnant women from Maskwacis and the Wetaskiwin area. Data were collected from the participants box 2 antenatal risk SCoreS for WeTaSkiWin hospital MaSkWaCiS BirThS VerSuS non-maskwacis BirThS Percentage of Risk Score Antenatal Overall Who Are Risk Score Births First Nations Moderate risk 31% 64% High risk 7% 81% Sources: Alberta Health, Primary Health Care Division (2013), DTHR (2005), Hendriks (2004). box 3 PerCenTage of WoMen BirThing in WeTaSkiWin hospital Who received LiTTLe or no PrenaTaL Care Prenatal Care Time Period Percentage 2002 to % 2004 to % 2006 to % Source: DTHR (2008a). during their prenatal and postnatal visits by questionnaires. From November 2005 to February 2009, the APWP was funded by Alberta Health and Wellness and during this time 281 women participated in the program (from 2009 to 2010, the APWP was funded by Prairie Central FASD Network and from 2010 to the present, it has been funded by Primary Care Network). Pregnant women who used the clinic were being assessed and diagnosed earlier with a high-risk pregnancy and were provided with close monitoring for the rest of their pregnancy. Of the 281 women who attended the program from November 2005 to February 2009, 14 percent were younger than 17 years of age, 58 percent were between the ages of 18 and 25, and 28 percent were over the age of 26 (APWP, 2009; see Figure 1). Of all the deliveries in the hospital occurring from 2002 to 2007, the percentage of women having limited or no prenatal care has dropped. In 2002, 19.5 percent of women had limited February March 2014 Nursing for Women s Health 43

7 or no prenatal care but in 2007 the number dropped to 13.5 percent (DTHR, 2008a). The 2008 APWP annual report indicated that women felt that care delivery was more efficient and supportive of their needs than was mainstream health care. 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. Parents felt seeing the physician at the end of the visit and having her or him ask about health concerns that may have come up when talking to nurses was valuable (APWP, 2008, 2009). The annual report also stated there was evidence of returning clientele, with a 3 percent increase in women showing up as soon as they suspect they are pregnant. When women were asked who they preferred to see during their prenatal care, 54 percent of women stated they would prefer to see both a physician and nurse. Having a nurse available for prenatal care supplemented the services already provided by the physician (APWP, 2008). Forty-four percent of women stated that they quit drinking and using drugs once they found out they were pregnant, 39 percent decreased their smoking and 16 percent quit smoking (APWP, 2008). Information campaigns were also initiated for breastfeeding. Women were asked early in pregnancy about breastfeeding, so that they had more time to think about breastfeeding. As their due date got closer, nurses continued the discussion of breastfeeding. Fifty percent of women indicated wanting to breastfeed longer than 6 months and overall 98 percent said they planned on breastfeeding (APWP, 2008). Obstetric nurses provided anecdotal reports that more photo E. Tavares / flickr.com figure 1 numbers of apwp ParTiCiPanTS By age and year Less than or equal 17yrs Between ages 18 to 21yrs Between ages 22 to 25yrs Between ages 26 to 30yrs Greater than or equal to 31yrs Source: APWP (2009). 44 Nursing for Women s Health Volume 18 Issue 1

8 Aboriginal women attempted to breastfeed in the hospital, especially first-time mothers. Box 4 shows results of a survey of 281 participants of the APWP. The survey was implemented prenatally and postnatally to women attending the APWP from 2005 to Ninetyseven percent of women stated they would come back to the program with future pregnancies and 98 percent said the program met their needs. In addition, 98 percent stated they would recommend the program to family and friends (APWP, 2008). Twenty-three percent of women said they would not have accessed any prenatal care if it wasn t for the APWP clinic, care, nurses must understand the historical implications of past relationships between Aboriginal and non-aboriginal people. This is important because Aboriginal women are the gatekeepers to other family and community members accessing health services; therefore, they need to feel comfortable and safe in the care they receive (ANAC, 2009; IPAC-AFMC, 2009). Nurses can understand and implement sensitive ways of caring for women dealing with serious issues, such as crisis, drug use, intoxication and family violence, and can ensure that women not feel judged. Nurses can holistically integrate mental, emotional, spiritual and physical wellness into health to understand the Causes of Cultural insensitivity, We must each examine our own biases and 47 percent said that the prenatal clinic helped them access prenatal care earlier (APWP, 2008). When pregnant women were asked if they preferred appointments or the walk-in clinic, 60 percent preferred appointments while 35.5 percent preferred walk-in (APWP, 2008). implications for nurses Broad implications for nursing practice include the need for nurses to develop cultural awareness and to communicate with women and their families in a way that makes them feel safe and supported about prenatal care. Culturally safe practices help nurses and other clinicians reach a point of care that promotes collaborative relationships and empowers all stakeholders. To develop a deeper level of understanding of factors that influence how Aboriginal women perceive and access health box 4 apwp SurVey results Prefer to see both a doctor and nurse 54% Women would come back to program 97% Program met their needs 98% Recommend the program to family and friends 98% Women accessed prenatal care because of clinic 23% Accessed prenatal care earlier 47% Preferred appointments 60% Preferred walk-in 35.5% Returning clientele earlier in pregnancy 3% Source: APWP (2008). assessment, education and support. Nurses can ensure that services provided are on a continuum of care that involves various stakeholders and resources, including community agencies, health professionals, social workers and Aboriginal community Elders. Nurses can promote a partnership with pregnant women to help them actively participate in decisionmaking processes and have control over improving their own health (Calnan & Lemire Rodger, 2002). APWP participants have described lack of professionalism from health care providers as a barrier to health care (DTHR, 2008b). When women experience this treatment, it s shared rapidly throughout the community, which further deters others from seeking care until the last minute, or until it s too late (DTHR, 2008b). Nurses can enhance their cultural awareness by taking advantage of cultural safety workshops and other educational resources. Armed with this knowledge, nurses can provide a safe environment, explain procedures well, listen to questions and encourage clients to talk and ask questions. When nurses provide care with respect and without judgment, more women will access routine prenatal care, which in turn positively influences the birth experience for women and their families, and possibly affects future birth experiences (Hess, Lanig, and Vaughan, 2007; IPAC- AFMC, 2009). future Direction The APWP s model has been expanded to the Wetaskiwin Primary Care Network in partnership with a local obstetrician/gynecologist. The model has been examined to be implemented into the Aboriginal Women s Wellness Clinic, which provides health promotion and screening on prenatal care, sexually transmitted infections, contraception, gynecologic February March 2014 Nursing for Women s Health 45

9 services and cervical cancer screening. Community development and collaboration are ongoing and key for the promotion of health for Aboriginal women. The message of getting earlier prenatal care is supported in the community as women, agencies and health care providers work together through the continuum of care. The potential direction of the program is to hire a nurse practitioner or midwife in the Maskwacis community to provide prenatal care. The model of APWP can branch to other cultures with the same type of barriers or noncultural targets, such as socioeconomic status. Hiring Aboriginal nurses and support staff who understand the cultural practices of the women being cared for would enhance the delivery of the program. Conclusion By addressing health disparities through a culturally safe approach, the APWP improves access to vital prenatal health care services for pregnant Aboriginal women. The APWP model sets a standard of care for Aboriginal communities involving relationships between health care providers and communities. The model could be beneficial for other communities to follow because it promotes a team approach to prenatal care, addresses barriers of transportation, provides a one-stop shop and educates staff to provide culturally safe care. NWH references Aboriginal Nurses Association of Canada (ANAC). (2009). Cultural competence and cultural safety in nursing education: A framework for First Nations, Inuit and Metis nursing. Ottawa, ON: Author. Retrieved from Happen%20Curriculum%20Project/FINALFRAMEWORK.pdf Aboriginal Prenatal Wellness Program (APWP). (2008). Annual report. Wetaskiwin, Alberta: Author. Aboriginal Prenatal Wellness Program (APWP). (2009). Aboriginal Prenatal Wellness Program statistics from questionnaires [unpublished raw data]. Wetaskiwin, Alberta: Author. Alberta Health, Primary Health Care Division. (2013). Community profile: Wetaskiwin County. Edmonton, AB: Author. Retrieved from WetaskiwinCounty.pdf Calnan, R., & Lemire Rodger, G. (2002). Primary health care: A new approach to health care reform. Ottawa, ON: Canadian Nurses Association. Retrieved from media/cna/page%20content/pdf%20fr/2013/09/05/19/04/ phc_presentation_kirby_6602_e.pdf David Thompson Health Region (DTHR). (2005). Health report. Red Deer, Alberta: Alberta Health. David Thompson Health Region (DTHR). (2008a). Aboriginal health program: Summary results. Red Deer, Alberta: Alberta Health. David Thompson Health Region. (2008b). Minutes. Red Deer, Alberta: Author. Retrieved from documents/minutes/mar12_2008.pdf Health Council of Canada. (2011). Understanding and improving Aboriginal maternal and child health in Canada: Conversations about promising practices across Canada. Toronto, ON: Author. Retrieved from php?id=123 Hendriks, W. (2004). Prenatal doctor survey results [unpublished raw data]. Wetaskiwin, Alberta: Aboriginal Prenatal Wellness Program. Hess, D. J., Lanig, H., & Vaughan, W. (2007). Educating for equity and social justice: A conceptual model for cultural engagement. Multicultural Perspectives, 9(1), Retrieved from web.ebscohost.com.aupac.lib.athabascau.ca Indigenous Physicians Association of Canada and Association of Faculties of Medicine of Canada (IPAC-AFMC). (2009). First Nations, Inuit, Metis health core competencies: A curriculum framework for undergraduate medical education. Ottawa, ON: Health Canada First Nations and Inuit Health Branch. Retrieved from Kuran, H. (2000). Residential schools and abuse. Kahnawake, QC: National Indian & Inuit Community Health Representatives Organization. Retrieved from wohealth7.html National Aboriginal Health Organization (NAHO). (2006). Exploring models for quality maternity care in First Nations and Inuit communities: A preliminary needs assessment. Ottawa, ON: Author. Retrieved from ModelsforQualityMaternityCareFirstNationsandInuitCommunities.pdf National Aboriginal Health Organization (NAHO). (2008). Cultural competency and safety: A guide for health care administrators, providers and educators. Ottawa, ON: Author. Retrieved from www. naho.ca/documents/naho/publications/culturalcompetency.pdf Royal Commission on Aboriginal Peoples. (1996). Chapter 3: Health and healing. In Report of the Royal Commission on Aboriginal People, volume 3: Gathering strength (pp ). Ottawa, ON: Canada Communications Group. Retrieved from caid. ca/rrcap3.3.pdf Royal Commission on Aboriginal Peoples. (2006). Chapter 3: Health and healing. Ottawa, ON: Author. Retrieved from www. collectionscanada.gc.ca/webarchives/ / Smylie, J. (2001). A guide for health professionals working with Aboriginal peoples: Aboriginal health resources [policy statement]. Ottawa, ON: The Society of Obstetricians and Gynaecologists of Canada. Retrieved from sogc.org/wp-content/ uploads/2013/01/100e-ps5-march2001.pdf Truth and Reconciliation Commission of Canada. (2012). Canada, Aboriginal peoples, and residential schools: They came for the children. Winnipeg, MB: Author. Retrieved from www. attendancemarketing.com/~attmk/trc_jd/resschoolhistory_2012_02_24_webposting.pdf 46 Nursing for Women s Health Volume 18 Issue 1