Understanding and Improving Aboriginal Maternal and Child Health in Canada: Conversations about...

8/13/2019 Understanding and Improving Aboriginal Maternal and Child Health in Canada: Conversations about Promising Practices across Canada

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augus t 2011

Understanding and Improving AboriginalMaternal and Child Health in CanadaConversations about Promising Practices across Canada


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U n d e r s t a n d i n g a n d I m p r o v i n g A b o r i g i n a l

M a t e r n a l a n d C h i l d H e a l t h i n C a n a d a

Created by the 2003 First Ministers Accord on Health Care Renewal ,

the Health Council of Canada is an independent national agency that

reports on the progress of health care renewal in Canada. The Council

provides a system-wide perspective on health care reform in Canada,

and disseminates information on best practices and innovation across

the country. The Councillors are appointed by the participating

provincial and territorial governments and the Government of Canada.

To download reports and other Health Council of Canada materials,

visit www.healthcouncilcanada.ca.

a b o u t t h e h e a l t h c o u n c i l o f c a n a d a


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Part A commentary by the Health Council of Canada

Introduction

Concluding comments

References

Part What we heard: A summary of regional sessions across Canada

Introduction

Setting the context

What participants said about the promising practices

What participants said about who has a role to play

Summary points

Appendix A A listing of promising practices by session

Appendix B Demographics and health indicators ofAboriginal maternal and child health

References

Acknowledgements

c o n t e n t s


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part 1

A commentary by the HealthCouncil of Canada


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H e a l t h C o u n c i l o f C a n a d a4 U n d e r s t a n d i n g a n d I m p r o v i n g A b o r i g i n a lM a t e r n a l a n d C h i l d H e a l t h i n C a n a d a

IntroductionThe problems facing Aboriginal Peoples need littleintroduction. The information on disparities(opposite) is a stark reminder that many FirstNations, Inuit, and Mtis a people have signicantly worse health and more challenging l ivingconditions than the larger Canadian population.

This cycle must be broken. In , the HealthCouncil of Canada began a multi-year project tolearn more about the crisis in Aboriginal health, with a focus on programs or init iatives thathave the potential to reduce unacceptable healthdisparities between Aboriginal and non-AboriginalCanadians.

In the rst year of this work, we set out to learnabout the health care of expectant mothers and

children from the prenatal stage to age six. Its welldocumented that better lifelong physical, mental,and spiritual health begins in childhood; thisis the place to start.1

The Aboriginal population in Canada currentlyhas a much younger demographic than thenon-Aboriginal population, 2 and a higher birthrate.3 In the last few years, a number of leadingorganizations have urged governments to focustheir attention on this vulnerable population. InJanuary and February of , the Health Councilheld a series of seven regional meetings acrossCanada to learn what is making a difference in thehealth of Aboriginal mothers and young children.We invited front-line workers (mostly in healthcare), academics, and government representativesfrom a mix of urban and rural, northern andsouthern settings, and representing First Nations,Inuit and Mtis communities. Many participantshad not previously met, and were eager tolearn about one anothers work, the issues theyface, and success stories.

Aboriginal disparitiesat a glanceWhile there is diversity among First Nations,Inuit, and Mtis populations, there aresignicant overall health and economicdisparities between the Aboriginal andnon-Aboriginal Canadian population:

Aboriginal people are much more likely to livein poor health and die prematurely.

Aboriginal people have a higher burden ofchronic conditions and of infectious disease.

Aboriginal children are more likely to diein the rst year of life.

Aboriginal people are more likely to live inpoverty, which has a domino effect on otheraspects of their lives. They are more likelyto go hungry, to suffer from poor nutritionand obesity, and to live in overcrowded,substandard housing.

Aboriginal people are less likely to graduatefrom high school, and more likely to beunemployed. 4

One 2007 study evaluated Canadas AboriginalPeoples using the UNs Human DevelopmentIndex, which looks at factors such as educationlevels, income, and life expectancy. Canadaconsistently appears on the Top 10 of the UNslist, but according to this study, CanadasAboriginal Peoples would rank in 32nd place. 5

More information about health disparities canbe found in Appendix B on page 43.

a) Section 35 of Canadas Constitution Act , 1982 recognizes three distinct Aboriginal Peoples in Canada: First Nations (Indian), Inuit and Mtis.


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H e a l t h C o u n c i l o f C a n a d a

A large proportion of participants were front-line workers and program managers, who provideda real-world perspective on Aboriginal health. It isone thing to read an academic evaluation of aparenting program and another to hear a group offront-line providers talk about teaching it in theircommunity: Its great. Its easy to use . It works.I learned a lot myself and now I use it with myown kids.

Its important to note that we had fewer Inuit andMtis representatives than we had hoped for atthe sessions; the majority of participants were fromFirst Nations communities. In addition, there were few participants from remote nor therncommunities, which face additional challengessuch as the general availability of health care,access to affordable, nutritious food, and the needto send women away to give birth. The interestsand afliations of the participants in our sessionsunderstandably dened the types of issues theychose to discuss and the examples of successfulprograms they put forward.

This phase of the Health Councils work was notintended to be an academic project; it is not acomprehensive overview of all the issues affectingthe health care of First Nations, Inuit, and Mtismothers and children, or of all the promising

practices that exist. Our goal was to capture on-the-ground information about whats working frompeople in the eld. A summary of all proceedingsfollows in the second part of this report, andan online compendium of promising practices isavailable atwww.healthcouncilcanada.ca.

In this commentary, we offer a window intothe experiences and insights of many people whoprovide care to Aboriginal women and theirchildren. What they said complemented andsometimes questioned current thinking about the

best way to approach Aboriginal maternal andchild health issues across Canada.

It takes a healthy village to raise a healthychild: a holistic view of healthMany participants stressed that good-qualityhealth care for expectant mothers and youngchildren is not just prenatal care, delivery,postnatal care and checkups; it involves lookingat the womans life as a whole. As one participantsaid, We dont just talk about the fac t thatshes having a baby. Hows she doing at home?Hows her mental health? What are herrelationships like?

It has been well documented that the circum-stances of a persons life and the associatedphysical, mental, and emotional impact play asignicant role in health.1 Canadian governmentshave recently started to make these connections bydeveloping policies that focus on issues suchas poverty reduction,1 but Aboriginal communitieshave always believed that health requires a focuson the bigger picture. A healthy life is seen as a balance between the physical, spiritual, emotional,and mental parts of ourselves.

The typical Western medical view tends to considehealth issues in isolation, rather than looking atthe cultural, family, and community context. Thisis signicantly different from the Aboriginal world view. Participants said there can be a clash of

values, with Western health care providers valuingcredentials, and Aboriginal people valuing the wisdom of traditional knowledge.

Participants shared examples of some primaryhealth care centres and womens or birthingcentres that integrate the two approaches, althoughthese types of centres are not as widespreadas they could or should be. Several participantsnoted that hospitals still have a long wayto go in developing cultural sensitivity towardsAboriginal people.


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People must understand the legacy ofresidential schoolsWhen asked to share the issues facing theircommunities and standing in the way of bettermaternal and child health, participants spokefrankly and with some frustration. Most of theircomments were about the life circumstancesof the mothers and children they see, rather thantheir health issues. Poverty was at the top of thelist, dened in many ways: nancial, emotional,and spiritual. Participants spoke about poorliving conditions, overcrowding and a lack ofhousing, and a lack of affordable or easily availablenutritious food factors that have cascadingeffects on personal health and family relationships.Domestic violence towards women and children,lack of self-esteem, addictions, and fetal alcohol

spectrum disorder (FASD) came up repeatedly.We heard less than we had expected on sometopics (there was very little discussion of well-documented health care issues among Aboriginal women and children, such as diabetes, low birth weights, or breastfeeding challenges) andmore on broader issues affecting Aboriginalcommunities as a whole. In particular, we heardabout the impact of the traumatic exper ience ofcolonization the imposition of Western valuesand way of lifeand residential schools.

In some of the sessions, participants expressedconcern that many non-Aboriginal Canadians including those who work in health care, child welfare serv ices, and government ofcessimplydont understand or value the Aboriginal world view, and dont understand how the mult i-generational effects of the residential schoolexperience have had an impact on the entire culture.

Many children who were abused and shamedfor their Aboriginal heritage in these schools grewinto adults who had difculty forming healthyrelationships with other people, including theirown partners and children. These childhoodexperiences have created many lives andcommunities of poverty, mental health issues,addictions, and domestic violence.

Part of the focus of Aboriginal healing effortsis to help people understand their own experiencesin the broader context that the pain they havesuffered and may have passed on to their families isthe result of these experiences. The devastatingeffect of residential schools has been compared topost-traumatic stress disorder (PTSD) that affectsa whole culture, not just individuals.6,7 You muststress this in your report, said several participants.This is still in our minds and our souls and is being passed on through the generations. The healing isstill going on.

This message is not getting through to the broaderCanadian public. Non-Aboriginal Canadiansmay have heard about problems in Aboriginalcommunities, but many still dont understand whyAboriginal issues persist, or how communitiescan be supported. In a major survey of urbanCanadians (the Urban Aboriginal Peoples Study),

nearly half of non-Aboriginal respondents hadnever read or heard anything about residentialschools8 despite the federal governmentslandmark public apology in and the ongoingnational process of reconciliation and healingthat is meant to address these effects.

Many non-Aboriginal survey respondentsalso said they believe that Aboriginal people havethe same or better socio-economic and otheropportunities as any other Canadian 8 despitedata on lower high school graduation rates,

worse health, reduced life expectancies, andan epidemic of poverty that has been described by the Assembly of First Nations as the singlegreatest social justice issue in Canada today.9


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Participants in the regional sessions said that ahistory of paternalistic treatment and racism,coupled with a continued lack of understandingof the challenges faced by First Nations, Inuit,and Mtis people, has created a sense of warinessamong many Aboriginal mothers they serve.This can be a signicant barrier to good healthcare. Women are afraid to seek out care because offears of racism, or of being judged for their behaviour; theyre afraid of the unknown, or oflooking ignorant; and theyre afraid that theymight reveal something which will lead to theirchildren being removed by child welfare authoritiesApproximately one in ve ( %) of substantiatedchild welfare investigations involve children ofAboriginal heritage.10 The most common formof child mistreatment in Aboriginal communities

is not physical abuse but neglect, which is linkedto family poverty.11

Some positive changes are starting to happen inchild welfare systems across the country to addresthese concerns, but many of the participants atour meetings were not yet seeing improvements.At several sessions, there was signicant concernabout the continuing lack of coordination betweenchild welfare and health authorities.When childrengo into care, they cut us off from assisting thechild so relationships have to be es tablishedall over again, and this is very hard on the childand family.

Whats working?This simple but focused question promptedwide-ranging discussions on a broad selectionof programs, strategies, organizations, andpolicies that are making a difference in the livesof First Nations, Inuit, and Mtis women andchildren. A list of promising practices putforward in each region begins on page 24, and amore detailed online compendium is availableat www.healthcouncilcanada.ca.

Not surprisingly, strong collaboration andintegration underpin many of the promisingpractices. An important characteristic of theseprograms or strategies is the quality of

relationships involved

relationships ofmutual understanding, trust, and respectamong different governments, amonggovernment and non-government agencies, andamong Aboriginal and non-Aboriginal partners.

Participants gave many examples of goodworking relationships at the program level, anda number of particularly notable examplesinvolving federal, provincial, and First Nationspartnerships. Two models put forward were theTripartite First Nations Health Plan in British

Columbia, and the tripartite Memorandum ofUnderstanding (MOU) on First Nations Healthand Well-Being in Saskatchewan.

There were also two strong examples of cross-government and cross-ministry collaborationfocused on a common goal: both the CanadaNorthwest FASD Partnership and AlbertasFASD Cross-Ministry Committee are working toprevent fetal alcohol spectrum disorder (FASD) and to provide care and support to peopleliving with the condition.


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Participants also discussed a number of governmentstaff educational programs and health caretraining programs that are helping non-Aboriginalpeople to become more sensitive to Aboriginalissues and traditions. One example was theIndigenous Cultural Competency On-line TrainingProgram, delivered by the Provincial HealthServices Authority of British Columbia. At severalsessions there were discussions about the valueof Aboriginal-specic health centres such asOttawas Wabano Centre for Aboriginal Health, which provides not only health care services butsocial, economic, and cultural initiatives.

Stumbling over the system: funding, programcriteria, and other challengesIt took some time for participants to move fromdiscussing the problems to identifying solutionsthat are working. There were many conversationsabout burnout, both from working with familiesand trying to navigate the system.A lot of times people are thrown into work with the familieswithout the proper training. Money is thrown at you, but with no pol icies or procedures , youre just expected to gure it out. Mental health is ahuge issue, several participants said, but manyfront-line staff arent trained to recognize ormanage mental health issues.

At every session, participants talked about fundingchallenges. There is a shortage of stable, multi-yearfunding, and this affects the ability of Aboriginalcommunities to provide maternal and child healthservices comparable to those available to otherCanadians. Its like putting together a puzzle everyday with all the programs and funders, trying to piece something together.

At several sessions, participants also mentionedthat integration and coordination amongprograms can be hindered because they need tocompete for funding. There were many commentsabout the need for stable, long-term fundingfor programs and stafng, and for more flexibleprogram criteria that would t a communitysunique needs. There is often a gap between programs; families get dumped when they are nolonger eligible for a program, and then there isnothing for them until the child reaches the criteria for the next program and then they have tobuild all new relationships.

Participants also commented on the frustrationof dealing with ongoing jurisdictional issues between multiple levels of government (and theirdifferent programs), such as federal, provincial,territorial, or municipal governments, healthauthorities, and band councils. Funding policiescan shift with political agendas and changesin government, resulting in the loss of support forpromising programs and services. Participantssaid that governments initiate many great programsthat are responsive to the needs of Aboriginalpeople and incorporate all the attributes ofpromising practices but then funding ends andmany of the gains that have been achieved are lost.Sometimes a program will be dropped, retooled,and brought back a few years later.

Several participants said they would likegovernments to recognize that it takes time togrow promising pract ices, and perhaps evena generation to see the evidence of success.They thought that regular data collection andevaluations, together with common goals,partnerships, and trusting relationships, wouldencourage governments to commit to long-termsustainable funding and support.


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Participants recognized that a number of federalprograms are making progress, such as theCanada Prenatal Nutrition Program, Maternal andChild Health program, and Aboriginal Head Start(see page ), but they want to see these programsavailable to more Aboriginal people, morecomprehensively funded, and easier to access byAboriginal staff and communities who maylack the capacity or resources to write fundingproposals. I got less than half of the fundingI applied for, which means I cant run the scope ofthe program I had planned. One communityspent thousands of dollars on a grant writer to puttogether a successful proposal. I dont have thatkind of money to pay someone to get the program.Cant they make funding proposals easier tounderstand and attain? They need to be written for

communities, not in government jargon. Andthere should be some kind of government liaisonto help some of these small communities justdont speak the government language.

While some front-line workers were interestedin information about strategies that had workedfor other programs or regions, others believedtheir own circumstances particularly community,program, or government leadership would makesimilar approaches difcult. Front-line workersfrequently commented that their budgets didntprovide them with opportunities to attendconferences, and that the ability to meet others inthe eld and gain a broader perspective was themost valuable part of the Health Council regionalsessions.

Culture is good medicineEmbedded in many success stories we heard wasthe importance of rebuilding what was strippedfrom Aboriginal Peoples, such as knowledgeof their language and traditions, pride in theirculture, and self-determination. Non-AboriginalCanadians dont necessarily understand theimportance of honouring Aboriginal practices andintegrating them with modern health care orother services. One front-line provider describeda common misunderstanding: People dont seehow Aboriginal needs for cultural understandingare different from the needs of the immigrant families in my program.

Aboriginal Peoples and immigrant populationsshould not be compared. There is a long andpainful history of efforts by past governmentsto deliberately eliminate Indigenous culture; oneof the starkest reminders of this is the infamousstatement that the intent of residential schools was to kill the Indian in the child.12

Rebuilding the cultural pride, traditions, andownership of Aboriginal lives is not just a moralobligation. The Aboriginal Healing Foundationstated that rediscovering pride in ones culture andidentity is good medicine.13 One landmark study concluded that communities that had

taken active steps to preserve and rehabilitate theirown cultures and languages had dramaticallylower youth suicide ratesan important indicatorof overall community health.14 One participant ina Health Council session compared the integrationof mind, body and spirit to the three strands ofa braid, a metaphor she uses to teach healthcare providers about the importance of seeingthe full picture in Aboriginal health.15


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Educating children and their parentsThe importance of education came up repeatedlyat every regional sessionspecically theimportance of prenatal education, support for newparents, and preschool programs for youngchildren. Participants said that many of the newparents they see are teenagers who lack generallife skills as well as knowledge about raisingchildren and creating a home.

Participants shared anecdotal stories of the behaviour they see among young Abor iginalparents propping the bottle was one example which often stems from a lack of knowledgeabout child development and how to build a warmattachment to the baby. Parenting programsfocus not just on skills, but on creating a loving bond. Increasingly, a number of the programsfocus specically on teaching young fathers howto be involved with their babies and be healthy rolemodels. The importance of teaching goodnutrition and life skills, such as cooking came upmore than once. The parents we see are, . Friesand sh sticks: thats what they think is a meal.

Many parenting support programs and earlychildhood programs were put forward as promisingor as already-recognized good practices. Someparenting support is offered at home; other

programs are in primary health care centres orcentres that offer a broader range of support, suchas practical help to obtain housing and social benets. Some offer specic services for pregnant women and new mothers who have drug andalcohol issues. A centre called Sheway, located inVancouvers troubled Downtown Eastside, was heldup as a model at several sessions for its work insupporting women with complex challenges. TheLouise Dean Centre in Calgary, a school forpregnant and parenting teens, was also recognizedfor its comprehensive support for young parents.

Participants put forward many promising practicesthat integrate traditional approaches. One that was mentioned several times as an example inmaternal and child health was the Six NationsBirthing Centre in Ontario. Aboriginal midwivesprovide a balance of traditional and contemporarymidwifery services and programs, based onthe philosophy that birth is serious, sacred, andcarries a continued responsibility to the child.The Centre also provides midwifery training.

Participants discussed the struggle to return birthingto communities as one example of the importanceof culturally sensitive care. There is currently aneffort to return birthing to Aboriginal communities,particularly in the North. Pregnant Aboriginal women whose communities do not have birthingservicessuch as a midwife or other appropriatehealth professionalare sent away from theirhome communities, often weeks before giving birth, to another community where these servicesare available. They are separated from their familiesand support systems at this critical time, and when they return home with their babies, manysmaller communities lack postnatal care servicesincluding breastfeeding support. A number ofthe promising practices discussed were about effortsto train Aboriginal midwives and to make birthand pre- and postnatal support more accessible inremote communities. One example of a majorgovernment initiative is Nunavuts Maternal andNewborn Health Care Strategy, which aims toreturn birthing to communities and to integratemodern medicine with traditional and culturallyrelevant practices. The Society of Obstetriciansand Gynaecologists of Canada was also recognizedfor its work towards an Aboriginal Birthing Initiativefor Canada. Further information is available atwww.sogc.org/projects/birthing-strategy_e.asp.


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Some words of praise for specic parentingprograms and resources turned out to be informalendorsements of larger initiatives. As one example,a group of home visitors funded by the federalgovernments Maternal and Child Health programspoke with enthusiasm about the clear instructionsand effectiveness of the parent training programthey were given to use.

The early childhood intervention programAboriginal Head Start was praised at severalsessions, both for general child development andfor teaching language and culture, but there wasalso some frustration that it wasnt more widelyavailable.My own granddaughter went through this program and i s ju st f lourishing. You can tell thedifference in grade school between the kids whowent to these programs and those who didnt. I triedto get more funding for this in our region andcouldnt. If they are really trying to help us, this program should be made avail able to all FirstNations children.

Participants also spoke about the importanceof early childhood education to set the stage forlong-term success. Aboriginal people face many barriers to a good education poverty in particular.The high school graduation rate is much lowerthan that of the larger Canadian population. This

has a domino effect that goes beyond individuallives. Communities would like more Aboriginalmaternal and child health care workers, but there isa lack of eligible candidates. Other issues are atplay as well: a shortage of health care providers inrural and remote areas; a lack of training, education,and apprenticeship programs in communities;and a lack of specic programs to train Aboriginalpeople in par ticular. Participants did identify somepromising programs most commonly midwiferytraining programs for Aboriginal women andmedical schools at some universities but theyadded their caveats:We need to support educationat an earlier stage to have enough graduates forthese post-secondary programs.

Getting access to culturally sensitive care

or any health care at allParticipants had a great deal to say about thistopic, starting with the barriers: There are problems with distance and t ransportation costs, and ashortage of trained health care workers. There arenot enough midwives, not enough prenatal orpostnatal care or general services (such as vision odental care), and a lack of specialized services forchildren with special needs, such as physiotherapyor mental health support. There is also a lackof support to diagnose and treat fetal alcoholspectrum disorder (FASD), and a lack of consultation with Aboriginal communities when the programsare designed. These challenges are even morepronounced in northern and remote areas.

One theme that came up repeatedly was the needfor improved and coordinated access to a teamof health care professionals who would provideculturally sensitive care. A model discussed atseveral sessions was the Rocky Mountain Houseprimary health care network. It works collaborativel with Firs t Nations communities to developprograms and coordinate access to team-based,holistic, and culturally sensitive care, which has leto better prenatal outcomes and relationships.

Some front-line staff on First Nations reserves

expressed frustration with the confusion andmisunderstandings that can arise when accessingprovincial resources. There were severaldiscussions about Jordans Principle, a child-rstapproach to resolving jurisdictional disputesabout the care of First Nations children withcomplex medical needs. It was clear that jur isdict ions are s till a t very different stages ofimplementing this approach.


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Concluding commentsBy the end of the seven regional sessions,participants had highlighted more than programs, policies, organizations, and strategiesthat they believe are making improvementsto the health of expectant Aboriginal mothersand young children.

On several occasions, participants discussed thefact that Prime Minister Stephen Harper iscurrently co-chair of a United Nations commissionon maternal and child health in the developing world. Participants said they hoped this work would help to turn the spotlight onto Canadianissues, focusing the federal governments attentionon Aboriginal mothers, their children, families,and communities. Though we did not startout with this in mind, it is fair to say that theHealth Council endorses their perspective.

Two prominent messages came out of theregional sessions:

. There is growing recognition that the livingconditions and circumstances of peoples liveshave a tremendous impact on health, and thatthese factors, called the determinants of health,are complex and intertwined. Nowhere is thislink between life circumstances and health more vividly apparent than in First Nations, Inuit,and Mtis communities.

Participants put these broader issues on the tableat the start of each regional sessionfactors suchas poverty, addictions, family violence, self-esteem,and the underlying legacy of colonization andresidential schools. They know that improvingthe health of the women and children theyserve requires a broader approach than just theservices they can offer.

There is no question that positive changes arehappening in regions across the country thanksto the efforts of Aboriginal communities andleadership, providers, and governments, but theseefforts are both tantalizing and frustrating topeople in regions where change is moving moreslowly: Why cant we have what they have? In the words of one part icipant, change often comesdown to both passion and leadership. Thissituation would be helped by improved funding,more flexible program criteria, and strongercollaboration between governments andAboriginal leadership to support broader thinkingon health and how to improve the determinantsof health in Aboriginal communities.

In our December report, Stepping It Up:Moving the Focus from Health Care in Canadato a Healthier Canada , we learned thatmomentum is building across the country totake action on the determinants of health andreduce health disparities. Governments andhealth care leaders are beginning to recognizethat they need to think differently and operatemore collaboratively if they want to improve thehealth of Canadians; leaving the responsibilityfor health to one ministry, or one level ofgovernment, is not the answer. People toldus these issues are being discussed with a newurgency. There is a real appetite for action.Given these factors, we believe there is asignicant window of opportunity for thefederal government to spearhead a new era ofdiscussions with the provinces and terr itoriesand Aboriginal leadership about the best ways to improve Aboriginal health.


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R E F E R E N C E S1 Health Council of Canada. (2010). Stepping it up: Movingthe focus from health care in Canada to a healthier Canada .Toronto: Health Council.

2 Statistics Canada. (2006). Aboriginal people: A young andurban population. Retrieved on May 6, 2011 fromwww41.statcan.gc.ca/2006/3867/ceb3867_004-eng.htm

3 Health Canada. (2005). Statistical prole on the healthof First Nations in Canada. Retrieved on May 6, 2011 fromwww.hc-sc.gc.ca/fniah-spnia/pubs/aborig-autoch/stats_

prol-eng.php

4 Canadian Population Health Initiative. (2004). Improvingthe health of Canadians. Ottawa: Canadian Institute forHealth Information. Retrieved from http://secure.cihi.ca/ cihiweb/products/IHC2004rev_e.pdf

5 Cooke, M., Mitrou, F., Lawrence, D., Guimond, E., &Beavon, D. (2007). Indigenous well-being in four countries:An application of the UNDPS Human Development Index toIndigenous peoples in Australia, Canada, New Zealand, andthe United States. BMC International Health and Human

Rights, 7 . doi: 10:1186/1472-698X-7-96 Braseld, C.R. (2001). Residential school syndrome. BCMedical Journal, 43 (2), 78-81.

7 Robertson, L.H. (2006). The residential school experience:Syndrome or historic trauma. Pimatisiwin: A Journal of

Abor iginal and Indigenous Co mmunity Health , 4 (1), 1-28.

8 Environics Institute. (2010). Urban Aboriginal PeoplesStudy-Main report. Toronto: Environics Insti tute. Retrievedfrom www.fnbc.info/urban-aboriginal-peoples-study-main-report

9 Assembly of First Nations. (2006/2007, Fall-Winter). AFNlaunches national campaign to eliminate poverty and createopportunity. Assembly of First Nations Health Bul letin. Retrieved from http://64.26.129.156/cmslib/general/HB06-FL.pdf

10 Public Health Agency of Canada. (2010). Canadianincidence study of reported child abuse and neglect-2008:Major ndings. Ottawa: PHAC. Retrieved fromwww.phac-aspc.gc.ca/ncfv-cnivf/pdfs/nfnts-cis-2008-rprt-eng.pdf

11 National Collaborating Centre for Aboriginal Health.

(2009/2010). Abor igin al an d non -Aboriginal children inchild protection services. [Fact sheet]. Retrieved fromwww.nccah-ccnsa.ca/docs/fact%20sheets/child%20and%20

youth /NCCAH_fs_childhealth_EN.pdf

12 Prime Minister of Canada. (2008). Prime Minister Harperoffers full apology on behalf of Canadians for the Indianresidential schools system. Retrieved on May 12, 2011 fromhttp://pm.gc.ca/eng/media.asp?id=2149

13 Aboriginal Healing Foundation. (2006). Summary pointsof the AHF nal report. Ottawa: AHF. Retrieved from www.fadg.ca/downloads/rapport-nal-eng.pdf

14 Chandler, M.J., & Lalonde, C.E. (2008). Cultural continuityas a moderator of suicide risk among Canadas First Nations.

In L. Kirmayer & G. Valaskakis (Eds.), Healing traditions: Themental health of Aboriginal peoples in Canada (pp. 221-248). Vancouver: University of British Columbia Press.

15 Barney, L. The Braid Theory . Personal Communication.February 16, 2011.


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part 2

What we heard: A summary of regionalsessions across Canada


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In addition, it is equally important to frame anydiscussion about maternal and child health within the context of the determinants of healththat span all Aboriginal communities,2,3 as well asdeterminants that are specically highlighted by First Nations, Inuit, or Mtis Peoples.4,5,6 All ofthe Health Councils work applies this broadframework to understand the critical health issuesfacing First Nations, Inuit, and Mtis Peoples.

Our approach to understanding promisingpractices and the engagement process for theregional sessions

The Health Council commissioned StonecircleConsulting Inc., an Aboriginal-owned consultingrm, to organize, coordinate, and facilitateregional sessions to answer the question: If Canadawants to improve the health status of Aboriginalchildren as one way to reduce disparities, what promis ing practices around maternal and childhealth need to be either advanced or developed?

The purpose of the regional sessions was to hearfrom front-line workers, program managers andcoordinators, Aboriginal leaders, academics, healthauthorities, and federal, provincial, territorial,and municipal government representatives aboutmaternal and child health realities on the ground.As well, we aimed to be inclusive in our sessions

of on/off-reserve, urban, and status and non-statusAboriginal people.

It was not our intent to gather a complete nationalinventory of promising practices. Readers who work in the eld will notice omissions. What wedid capture at the sessions and in this documentare selected front-line accounts of programs andstrategies that are working to improve Aboriginalmaternal and child health. The issues and initiativesthat our participants chose to put forward are areflection of their particular afliations and

experience.

Dening promising practices

The term promis ing practice can be dened many ways. For this project, we dened it as a model,approach, technique, or initiative that is based onAboriginal experiences, that resonates with usersof the practice, and results in positive changesin peoples lives.7 A promising practice has thefollowing attributes:

is acknowledged to positively advanceAboriginal health status;

is inclusive of the interests and experiences ofmany;

is valued and supported by relevantstakeholders;

may be well known and/or has a history ofsuccess;

is adaptive, recognizing the importanceof community context for successfulimplementation; and

ideally is evaluated.

With this denition in mind, three questionsguided the regional sessions:

Whats working and making a difference inthis area?

What programs and initiatives have you heardabout elsewhere that you wish you had?

How can the information collected about thepromising practices be shared across the countryin an accessible and useful manner?


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Ottawa, ON January 20, 2011 Wabano Centre for Aboriginal Health

Halifax, NS January 21, 2011 Eskasoni Community Health Centre

Calgary, AB January 28, 2011 Elbow River Healing Lodge

Winnipeg, MB February 14, 2011 Prairie Womens Centre of Excellence

Vancouver, BC February 16, 2011 First Nations Health Council

Whitehorse, YK February 18, 2011 Taan Kwachan Council

Toronto, ON February 28, 2011 Native Canadian Centre of Toronto

3. Collaboration and integration

Bringing together, working together, combiningfunding or other collaborative approaches between Aboriginal maternal and child healthprograms and services, or linking with othercommunity programs and services (housing,employment, social services).

4. Training and human resources

Successful ways of recruiting, training, and retainingAboriginal people who work with and supportFirst Nations, Inuit, Mtis mothers and children.This topic can also include successful waysthat non-Aboriginal organizations and healthpractitioners are trained, recruited, or workin Aboriginal maternal and child health (culturalcompetency, cultural safety).

5. Policy and fundingBroad policies or funding programs at the federal,provincial, territorial, or Aboriginal governmentlevel that have improved Aboriginal maternaland child health; something that could be seen asa model or promising approach.

Our research also identied ve themes under which the practices could be grouped for purposesof discussion (recognizing that there may beelements of more than one theme in any promisingpractice):

1. Traditional knowledge and cultural approachesRevitalization and incorporation of traditionalknowledge, culture, or use of languages in maternaland child health programs and services; couldinclude programs that address wellness asopposed to illness and are holistic (emotional,spiritual, physical, mental, intellectual)approaches.

2. Com mun ity-b ased an d co mmu nit y-focuse d

approaches

Programs, services, and approaches that are

developed at the community level; or large-scalefederal, provincial, territorial, or regionalprograms that are adapted at the community level.

TABLE 1

Regional Locations

C I T Y L O C A L H O S TS E S S I O N D AT E


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Seven locations across the country were chosen based on ve cr iteria:

accessibility for First Nations, Inuit, and Mtisparticipants;

accessibility to urban, rural, and remote

Aboriginal populations; geographic regions of Canada; travel gateways; and availability of local host organizations

the Health Council engaged local Aboriginalorganizations to co-host the sessions.

The regional meetings featured plenary and smallgroup sessions focusing on critical issues inAboriginal maternal and child health and promisingpractices, which were grouped under the vetheme areas. While it is true that there are many

serious issues that need to be addressed, theparticipants were also eager to speak aboutpractices that were working. Positive change ishappening on many fronts. After identifying thepromising practices, participants discussedany patterns that emerged, and who had a role toplay in the sustainability of the practices. Eachregional session concluded with a plenarydiscussion about options for a resource toolkit toshare information about the practices in a waythat would be accessible and useful for workers at

various levels in Aboriginal maternal and childhealth care. Participants responded with a diverserange of ideas.

This proceedings summary includes a review andanalysis of the conversations that took place atall seven regional sessions. Individual proceedingreports were prepared for each of the sevensessions, and these are available on request. Inresponse to participants suggestions that a resourcetoolkit be produced from the sessions, the HealthCouncil has prepared an online compendiumthat includes descriptions of the promisingpractices, along with contact information. It isavailable on the Health Councils website atwww.healthcouncilcanada.ca.

The Health Council of Canada thanks allparticipants, local host organizations, and elders who participated in these sessions and extendsgratitude to them for taking the time to shareknowledge, experience, and recommendations.These sessions validated many of the HealthCouncils learnings from its scoping document.There is a critical need for participatory evaluationand for the sharing of promising practicesamong the community of practice. Indeed, we heard from par ticipants in their evaluat ionsthat attending these sessions gave them animportant across-the-country opportunityto network, discuss, and learn about promisingpractices in other jurisdictions and differentsettings.


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worse in northern and remote regions, with a lackof affordable access to nutritious food andquality housing (no available units, overcrowding,mould) as signicant problems. Aboriginalpeople also face many barriers to attaining a goodeducation. This in turn blocks children from movingout of dire life circumstances, not to mentiongaining access to health science careers, which limitsthe pool of Aboriginal people who can becomehealth providers.

Colonialism, racism, and residential schools havehad long-lasting impacts on many areas ofpeoples lives. This has resulted in intergenerationaltrauma that perpetuates a wide range of healthproblems. For instance, individuals were separatedfrom their communities, their families, theirculture and one another. As children were takenfrom their homes to residential schools, parentingskills were not nurtured and family connections were severed. The fallout of this can be seentoday in the form of low self-esteem, abuse, family violence, addictions, poor relationship and conflictresolution skills, high rates of single motherhoodand teen pregnancy, mental health issues, lackof cultural knowledge, and a plethora of chronichealth conditions.

Setting the context: critical issues affectingAboriginal maternal and child healthWhile promising practices were the focus of theseregional sessions, many Aboriginal people inCanada continue to live in dire circumstances andthe participants described these in some detail, before discussing what was working. The summaryof critical issues in this section illustrates theurgent need to ensure the development andexpansion of promising practices in maternal andchild health programming and service delivery.Selected demographic and health indicatorinformation in Appendix Bspeaks further tothese issues.

Key themes from the regional sessions

The participants in all sessions identied anddiscussed critical issues affecting Aboriginalmaternal and child health in their regions. Theirkey points are summarized here:

Determinants of health

Health and well-being issues were seen ascircumstances related to and intertwined with thedeterminants of health, which were identied askey factors in the lives of Aboriginal mothers andchildren. Poverty is extreme and participantsdiscussed how it is experienced on many levelsemotional, monetary, and spiritual. Poor living

conditions, overcrowding and lack of housing,poor-quality drinking water, and lack of foodsecurity have cascading effects on personal healthand family relationships. These issues are much


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Lack of self-care knowledge and a fear

of seeking help

Linked to the effects of colonialism, racism, andresidential schools, participants discussed howclients lacked knowledge about how to care forthemselves and their families. This included a lackof understanding and awareness about a rangeof health-related issues such as mental health, birthcontrol, family planning, and harm-reductionapproaches. They said the situation wascomplicated by apathy or a resistance to newprograms, based on the belief that nothing wouldhelp. They stressed that this was a multi-facetedproblem with many complexities. There is fear ofracism and being judged, combined with guiltand shame for ones circumstances. This situationresults in an unwillingness to disclose information

and therefore to seek help. Ultimately, there isa lack of trust in services and in the system, inparticular of the child welfare authorities, wherefear that their children will be apprehendedprevents mothers and families from seeking help.

Parenting knowledge, skills, and support

The need for parenting knowledge, skills, andsupport, particularly for young parents, wasa recurring theme. The example of fetal alcoholspectrum disorder (FASD) b illustrates thiscomplicated issue. Some parents themselves haveFASD or drug and alcohol addictions, which limittheir ability to manage their lives or the livesof their children. They need case management andsystem navigation support to help them access careand services (such as education or health) andto make life decisions. This long-term, intensivesupport is needed to break the intergenerationaleffects of colonialism, residential schools,and racism. In general participants highlightedthe need for improved understanding of,and support for, child development, specically

attachment and bonding, general literacy andnancial planning skills.

Lack of access to culturally relevant care

There are two sides to this issue. On one side,communities that want to provide culturallyappropriate care struggle due to a lack of Aboriginamaternal and child health care workers. This iscomplicated by a systemic shortage of healthproviders, a lack of Aboriginal health humanresource training programs, and a lack of training,education, and apprenticeship programs incommunities. On the other side, there is (in someareas) a lack of understanding about the diversityamong First Nations, Inuit, and Mtis people.Non-Aboriginal health practitioners have, in somecases, shown discrimination or ignorance ofAboriginal cultures, realities, and challenges. Theris not enough emphasis on the importance ofcultural practices or enough acceptance or

integration of traditional teachers/elders and their wisdom and experience into the health caresystem. This has led to health care services thatare often not culturally relevant or sensitive.

Participants discussed the struggle to return birthing to communities as one il lustration ofthis lack of cultural awareness. PregnantAboriginal women are routinely sent out of theirhome communities, often weeks before giving bir th, to have their babies in unfamiliar sett ings,separated from their family and cultural supportsystems.

b) Fetal Alcohol Spectrum Disorder (FASD) is a disability resulting from prenatal exposure to alcohol. It is an umbrella term increasingly usedto describe the spectrum of disabilities (and diagnoses) associated with prenatal exposure to alcohol. FASD is not itself a diagnostic term: rather,the diagnoses under the FASD umbrella include Fetal Alcohol Syndrome (FAS); partial FAS (pFAS); Alcohol-Related Neuro-developmental Disorder

(ARND); and, Alcohol-Related Birth Defects (ARBD).8


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to other Canadians. There are many facets tothe funding issue funding models are complicated,disjointed, short-term, and reactive. Fundingpolicies lack a focus on prevention and communityhealth. They do not recognize traditionalgrassroots approaches as legitimate, yet it is theseapproaches that are often the key factor in the successof programs aimed at improving maternal andchild health. Small short-term grants result indisjointed programs, piecemeal approaches, andlack of continuitya funding approach thatfalls short of addressing complex problems andtherefore hinders the ability to make lastingchanges over time. Funding policies often shift with political agendas and changes in government,resulting in the loss of promising programs andservices, sometimes before they have been evaluated

or have demonstrated their effect. In the sessions,there was recognition and agreement thatpromising practices require time to grow.Governments initiate many great programs thatare responsive to the needs of Aboriginal peopleand incorporate all the attributes of promisingpracticesthen funding ends and many of thegains that have been achieved are minimized if notlost. Funding for First Nations is not availableto Mtis and some funding for Inuit is administereddifferently by different territories and provinces.

This leads to inequity. Finally, funding programsand priorities are often driven by top-downagendas that do not reflect Aboriginal needs, when what is needed is support for programs that have been identied at the community level as benecial .

Health care system access, integration,

and coordination

Participants described a number of factors thatplay a role in limiting access to health care.These factors include geography, transportationcosts, a lack of integration and coordination ofcommunity programs and services, and a lackof access to culturally safe and appropriate care.There is also a shortage of pr imary health careproviders , community midwifery, and prenatal/postnatal care. Participants noted a lack ofspecialized services, such as support for children with special needs, physiotherapy, healthpromotion, mental health and addictions services(including alcohol and smoking cessation), sexualhealth services, hearing and vision screening,and dental care. The situation is further complicated

and more severe in nor thern and remote areas.Funding

There are instances of longer-term fundingagreements (e.g. ve-year) between the federalgovernment and some Aboriginal groups, allowingfor stable funding of some services. Generallyspeaking, though, participants said that a shortageof multi-year agreements with adequate andstable funding is a persistent problem that affectsthe ability of Aboriginal communities to providehealth care services comparable to those available


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Funding is a challenging area that is related to thegovernance, infrastructure, and accountabilityissues outlined below.

Governance, infrastructure, and accountability

Aboriginal maternal and child health concerns

become mired in ongoing jurisdictional debatesand processes among governments (federal,provincial, territorial, municipal, Aboriginal),health authorities, and band councils. Services andprograms are often fragmented and delivered inrestrictive silos. Program criteria differ acrossgovernments and may not meet a communitysneeds, resulting in gaps in service. Even federalprograms that do address some of the gaps and areshown to be effective (e.g. Canada PrenatalNutrition Program, Aboriginal Head Start, andMaternal and Child Health) are not offered in allAboriginal communities. Participants describedthis as a piecemeal approach to funding withoutlong-term plans, accountability infrastructures, orevaluation strategies and frameworks that areparticipatory and community-driven. Participantsexpressed frustration that this lack of coordinationand integration has set them up for failure.

Health human resources

Recruitment and retention of front-line workersis difcult, particularly in smaller communities. The

high-stress nature of these positions leads tohigh turnover. Smaller communities cannot affordto hire full-time permanent staff, and so must llpositions with individuals who are not properlytrained or lack the required skills. No additionalprogram funds are provided for professionaldevelopment or upgrading staff skills. Communitynursing staff often do not have specialized trainingin maternal and child health. Moreover, people without professional training or paraprofessionalsare sometimes recruited to ll gaps in care;these individuals lack not only the cultural andhealing training but the health care-related trainingthat is necessary to work in complex social andcultural environments.

What participants said about thepromising practicesPositive changes and innovation are taking placeon many fronts in the areas of services, programs,and policies.

In this section, common features of promisingpractices are highlighted, along with selectedexamples from across Canada that show how and why they are successful. A grid with the full listof promising practices by regional session andtheme is included in Appendix A. Descriptionsand contact information can be found in an onlinecompendium on the Health Councils website.

Common features of promising practicesHolistic approach

A holistic approach is vital to Aboriginal maternal

and child health. The physical, mental, social,spiritual, and emotional components of health areinseparable. Aboriginal mothers and childrencannot be considered in isolation; they are part ofa larger family unit and a network of relationshipsin their community. The entire community a healthy community must be involved inconnecting and supporting mothers and children,including fathers, elders, youth, aunts, uncles,grandmothers, grandfathers, fr iends, neighbours,and the political leadership.


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H e a l t h C o u n c i l o f C a n a d a24

Traditional knowledge and cultural practices

Traditional knowledge and cultural practices playa fundamental role in rebuilding and strengtheningthe Aboriginal spirit, thereby addressing health-related problems, such as chronic disease, addiction,and violence, which arise from a broken spirit,mind, and body. It is critical that traditionalknowledge and cultural practices be incorporatedinto health care delivery and be considered afundamental component of early interventionand education strategies for young children, as wellas parenting education programs. To authenticallyincorporate traditional practices, it is not enoughto layer a veneer of traditional knowledge overa mainstream Western medicine approach. Asparticipants told the Health Council: Communitiesneed to own [their] knowledge, validate it on

[their] own terms and then share it with Westernapproaches to health this is the foundation.

Wellness, not illness

Related to a holistic approach is the need to shiftfrom a focus on treating illnesses to creating wellness wellness of the person, the family, andthe community, which involves a shift fromlinear biomedical thinking to interactions andrelationships. Successful practices bring peopletogether; increase community connections;improve knowledge and access to healthyalternatives and lifestyles; incorporate traditionalceremonies, language, and knowledge; and treat birthing as a celebration, not a s ickness thatmust be managed by health professionals. Thereality is that prevention and health promotionprograms are often the rst to be eliminated whengovernments make difcult budget decisions,or they are incorporated as an afterthought after

core medical services have been established.c

Selected examplesof promising practicesacross Canada

Six Nations of the Grand River Tsi Non:we lonnakeratsthaOna:grahsta Maternal and ChildCentre, Ontario helps Aboriginalwomen give birth to healthy babiesand promotes the seriousness,sacredness and the continuedresponsibility of giving birth. TheCentre provides a continuum oftraditional and contemporary servicesand programs, including an AboriginalMidwifery Training Program.

Inuulitsivik C.L. S.C Maternities,Nunavik region, Quebec is a modelfor culturally relevant, traditionalknowledge-based maternal and childhealth. This program in the Inuitregion of Nunavik (one of four Inuitregions in Canada) brings birthing andmidwifery training close to home ordirectly into the community respecting the Inuit belief system andbuilding community capacity. Cultureand community connectedness areembedded in the practice.

It was highlighted as a best practice ina paper prepared for the RoyalCommission on Aboriginal Peoplesmore than 15 years ago.

Sheway, British Columbia is apartnership initiative that bringstogether government and thecommunity to provide comprehensivehealth and social services, includingoutreach to a vulnerable populationwith highly complex needs. Holisticcare is based on a determinantsof health framework and is provided ina collaborative and respectful manner.

Grassroots Grandmothers Circle,Nova Scotia. The Mi'Kmaki Nugumijkare L'nu grassroots grandmothers.Based on the Seven Sacred Teachings,

grandmothers provide guidance andadvice for parents, advocate forcommunities, strengthen traditions,empower families, and instill pride.

Language Nest InuaggualuitProgram, Nunatsiavut region,Newfoundland and Labrador is a language immersion programfor babies and toddlers for therevitalization of the Inuktitut language.Based in Hopedale (in the Inuit region

of Nunatsiavut), it provides a senseof pride, and encourages languagerevitalization and respect for traditionand culture.

Ahp-cii-uk Aboriginal LeadershipInitiative, B ritish Columbia meansgoing the right way in theNuu-chah-nulth language and is aninnovative BC-based approach to FirstNations economic and social communitydevelopment. Capacity building andcommunity driven, the initiativehas many projects underway includingrebuilding a trail and developinga multi-use lodge, a spiritual healingcentre, and an art market.

The Rocky Mountain Primary CareNetwork (PCN), Alberta works

collaboratively with the Sunchildand OChiese First Nations to developprograms and coordinate access toa continuum of team-based, holistic,and culturally sensitive c are, resultingin improved prenatal outcomes andrelationships.

c) While the issue of evaluation of prevention and health promotion programs and services is a complicated one that would have an impact ondecision-making to eliminate programs and services, this topic was not discussed at the sessions.


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H e a l t h C o u n c i l o f C a n a d aU n d e r s t a n d i n g a n d I m p r o v i n g A b o r i g i n a lM a t e r n a l a n d C h i l d H e a l t h i n C a n a d a

An authentic approach involves recognition andacceptance of traditional practices and knowledge,and respect for their credibility; recognition andacknowledgement of diversity among Aboriginalpeople; language revitalization and inclusion inearly childhood development and parentingprograms; ensuring that parents and children areconnected to and can learn from elders and theircommunities; programs that are communitydriven and owned; training more Aboriginal healthcare providers; and training non-Aboriginalproviders to ensure cultural competency thatmoves beyond awareness into implementation andensures access to equitable care.

Cultural sensitivity and safety in caretraining and delivery

Cultural sensitivity is an important component ofall health professional training and service deliveryand should be supported by policies, guidelines,and a range of methods for delivering programs/carein a culturally safe manner. Programs and services

should be client-centred, at times client-driven, and be delivered through a par ticipatory approach.

Coordinated access to a team of

multidisciplinary front-line professionals

Some leading promising practices offer a model of

care that addresses the determinants of health,and provides culturally sensitive and holistic care.

Community ownership and determination

Communities need to own their own healthprograms and processes. Policies and programsthat come down from on high may lack culturalsensitivity, as well as an understanding of therealities in communities, and what will work in thecontext of a particular community. Governmentshave an obligation to provide funding, butcommunities must be allowed to determine how

to design and deliver the programs, includingevaluation and accountability mechanisms.

Southwest Ontario Aboriginal AccessCentre is a primary health care facilitythat provides holistic care by promotingWestern and traditional care thatsupports the determinants of health.It is commun ity based and c ommunitydriven, and receives support fromthe federal Maternal and Child Healthprogram.

The Aboriginal Prenatal WellnessProgram: Wetaskiwins Community-based Program, Alberta offers care inclose proximity to several reserves.Non-Aboriginal providers understandand respect how Aboriginal peopleinterpret and experience illness; theyrespect and acknowledge the socio-economic circumstances and developa full continuum of care working

in close collaboration with communityleaders, resulting in improved pre nataloutcomes and relationships.

Nova Scotia: Through the provinciallymandated Mikmaq Family andChildrens Services of Nova Scotia, a province-wide process has beenestablished to ensure that First Nationschildren receive the same servicesavailable to other children in NovaScotia in similar geographic locales.

The process provides a mechanismfor dispute resolution in addressingchildrens needs, including specialmedical requirements.

Regina QuAppelle Health RegionsEagle Moon Health Ofce (EMHO),Saskatchewan takes a holisticapproach to health, understandingthat complete health encompassesmental, physical, emotional, andspiritual well-being. The Eagle MoonHealth Ofce brings First Nations andMtis community members togetherwith health workers to collaborateand work toward meeting the holistichealth needs of the population.The EMHO has been recognized asa framework to be consideredby the Regional Health Authorities

in the province.

The Nunavut Maternal and NewbornHealth Care Strategy of the Departmentof Health and Social Services isdesigned to guide the developmentof care options and the deliveryof services in a way that integratesmodern medicine with traditional andculturally relevant practices.

Canada Northwest Fetal AlcoholSpectrum Disorder Partnership(CNFASDP) is an alliance of seven

jur isd ict ions (four Western prov incesand three territories) that isworking towards the developmentand promotion of an interprovincial,territorial approach to prevention,intervention, care, and supportof individuals affected by FASD.It is recognized as a successful modelof cross-governmental collaboration.

Strengthening Families Maternaland Child Health Program (SF-MCH),Manitoba is a partnershipco-management model and a province-wide, family-focused home visitingprogram for pregnant women,fathers, and families of infants and

young children from 0-6 yearsof age. The Assembly of ManitobaChiefs (AMC) and First Nations InuitHealth (FNIH) have agreed on aco-management structure with FNIHproviding the administration andfunding directly to the communities,and AMC providing the regionalsupport to the pilot sites, with the FirstNations Advisory Committeeoverseeing the overall implementationof the program.


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Successful practices are based on Aboriginalownership of the service and the development oflocal programs that address each communitysdistinct needs. A key component is ensuring that women play a central role in dening andparticipating in their care. This being said, the nextthree points on collaboration and integration,stable funding, and alignment of federal, provincial,territorial, and regional policies, together withcommunities, are integrally related to this feature.

Collaboration and integration

Maternal and child health should be a sharedresponsibility that is acknowledged and supported by policies and guidelines. On an informal leveland often in the absence of formal collaborationand integration mechanisms local programsare successful because of informal relationshipsamong providers who pool resources and supportone another in a variety of ways. An importantcharacteristic of collaboration and integrationis the relationship building, mutual understanding,

and respect that develops between Aboriginal andnon-Aboriginal partners.

On a formal level, programs are successful becausediverse people come together and form partner-ships among levels of government and government

departments, together with community-levelorganizations, First Nations, Inuit, and Mtisgovernments and organizations, health careproviders, and others are key. When this happens,there is positive change.

Align ment of federal , prov inc ial , te rr itori al , andregional governments, together with

Aborigi nal lea der shi p an d communiti es

When practices work well , it is because they arenot constrained by jurisdiction; they aresustainable with secure funding and are community-

owned and driven. All levels of government work towards common goals and in partnership with communities.

Selected examplesof promising practicesacross Canada

Seventh Generation Midwives,Ontario is an urban collective ofAboriginal midwives in Toronto,working directly with clients and arange of partners including hospitals,universities, research centres,and community health organizations.Services assist pregnant womenand recent mothers with holistic andculturally sensitive maternity carefrom conception to six weeks postdelivery. Everyone involved benets:clients and their families,the community, medical students,hospital staff, and providers.

Healthy Beginnings, SupportiveCommunities: A Strong Future MtisMaternal and Child Health DVD developed by the Mtis Centre at theNational Aboriginal HealthOrganization, is based on extensiveconsultations with Mtis parents,elders, midwives, and other maternalcare providers. Themes discussed

in the DVD include cultural continui ty,birthing options, historical birthingpractices, breast feeding, self-carefor pregnant women, and the roleof community in raising children.

Sioux Lookout Meno Ya Win HealthCentre, Ontario is a fully accreditedacute care and extended carefacility. Governed by Aboriginal andnon-Aboriginal people, it is an exampleof how federal, provincial, andAboriginal health authorities cancome together to provide a full rangeof hospital and community outreachservices.

Memorandum of Understanding(MOU ) on First Nations Health andWell-Being in Saskatchewan. The

Federation of Saskatchewan IndianNations (FSIN) Tripartite MOU is an

agreement between the federal andprovincial governments and FSIN toimprove the delivery of health servicesby reducing duplication, closing gaps,and improving the coordination andefcacy of the health care system. Theagreement includes a 10-year healthand wellness plan and represents anopportunity to improve health.

First Nations Health Council, BritishColumbia. A Tripartite AboriginalMaternal and Child Health Committee,which includes representatives fromFirst Nations, Inuit and Mtis commun-ities and the federal and provincialhealth systems, was establishedin 2008 to lead the implementationof maternal and child health actions.Key priorities include a Safe SleepInitiative for Aboriginal commun ities;early childhood screening programs fornewborn hearing, vision, and dentalcare, offered in schools and on reserve;and an Aboriginal doula initiative,which involves providing non-medicaland non-midwifery services (physicaland emotional) to women, leading upto and during labour and delivery.

New Brunswick Community HealthCentres are a network of centresfocused on outcome and evidence-based practice. They were praised forthis outcome or goal-oriented focus(rather than being task f ocused),which is seen as being very importantfor supporting a population-healthpromotion approach and a community-driven model.


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Stable funding

Long-term, multi-year, stable, and adequate levelsof funding support successful, sustainableAboriginal maternal and child health programming.

Evidence and accountability

Outcome-focused programs need to be based onknowledge of what works (i.e. desired outcomes), which comes in part from paticipatory evaluat ion.Results of evaluations can be used to respond toaccountability requirements of funders, but also asa tool for the community to strengthen and adapttheir programs based on evidence.

Participants said there needs to be a commitment to support emerging promising practices.Governments initiate many programs that aredesigned to be responsive to the needs of

Aboriginal people and incorporate all the attributesof promising practicesthen funding ends andmany of the gains that have been achieved areminimized if not lost. Recognition and agreementis needed that it takes time to grow promising

practices and perhaps even a generation to seethe evidence of success. Regular data collectionand evaluations, together with common goals,partnerships, and trusting relationships shouldgo a long way towards encouraging governmentsto commit to long-term sustainable fundingand support.

Supportive education and training

Successful initiatives ensure that Aboriginalchildren have access to educational systems and anopportunity to thrive in them, beginning withearly childhood education and continuingthroughout the cycle with social, emotional, andeconomic support. Other character istics ofsuccessful initiatives include amendments totraining processes that are respectful of andincorporate traditional knowledge and practices,the delivery of training in accessible ways,and acknowledgement of the life experiencesof students.

The Mikmaq (Aboriginal) HealthPolicy Framework, Nova Scotia, currently in development, was fundedby the Aboriginal Health TransitionFund (AHTF) until March 31, 2011. It isan initiative to improve access toprovincial, publicly funded health careprograms and services for allAboriginal people in Nova Scotiaas insured residents, while respectingthe special constitutional relationshipbetween the province and Aboriginalpeople in the context of a c omplex,inter-related federal / provincial / FirstNations health system.

Louise Dean Centre, Alberta is apartnership between the CalgaryBoard of Education, Catholic FamilyServices, and Alberta Health Services.

As a community-based interventionand prevention program for pregnantand parenting youth, the focusis on a comprehensive social, health,and educational program. Basedon a determinants of health modeland the provision of holistic care,it is recognized as a good exampleof collaboration among organizationsand governments working towardsa common goal.

National Collaborating Centre forAboriginal Health supports theadvan cement of Aboriginal publichealth goals and reduction ofinequities with groundbreakingresearch and know ledge developmentand translation.

Early Development Instrument (EDI),Manitoba is a tool for measuringschool readiness at the kindergartenlevel. It helps communities identifystrengths and target needs so they canbetter plan programming. It is wellrecognized inter nationally and used inAustralia with Indigenous populations.It currently does not involve all FirstNations communities but is seen as animportant tool.

Mtis Centre Health Literature andStatistical Databases, the Mtis Centreat the National Aboriginal HealthOrganization (NAHO) developed twodatabases in 2009. The rst database,developed in collaboration withStatistics Canada, contains hundredsof statistical tables and graphs gener-ated from the 2006 Aboriginal PeoplesSurvey. It is user-friendly and searchableby keyword. The second database isa searchable catalogue of peer-reviewedand grey literature on Mtis healthpublished over the last 30 years.

Northwest Territories Aurora College(Yellowknife) Nursing Program is part of a community-based collegesystem in the NWT that is providingculturally relevant training andeducational opportunities for Aboriginalstudents in rural and remotecommunities.

Behavioural Health Aide TrainingProgram, Nunatsiavut region,Newfoundland and Labrador is atraining program for Labrador Innuand Inuit communities to providestandardized skill development in thearea of FASD. The program is culturallyrelevant to both the Innu (a FirstNations group) and the people of theNunatsiavut Inuit region. It is anongoing collaborative effort among

multiple partners including theLabrador-Grenfell Regional HealthAuthority, the Mushuau InnuFirst Nation, the Sheshatshiu InnuFirst Nation, the Labrador SchoolBoard District and the NunatsiavutDeptartment of Health.


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What participant s said about who hasa role to playParticipants stressed that there must be sharedresponsibility. Governments have an importantrole to play by providing long-term/multi-yearsustainable funding, governance, and accountabilityframeworks, but the initiatives themselves needto be community-owned and driven. Governmentsare not responsible for xing the system alone.

Who is responsible for health care for

Aboriginal peoples?

Health Canada provides the following breakdownof responsibilities:

The federal government provides healthpromotion programs and public health services onFirst Nations reserves and in identied Inuit

communities. In remote and isolated areas, where

Best practices infederal programmingFederal programming for Aboriginalmaternal and child health falls largely

under the First Nations and InuitHealth Branch (FNIHB) and the PublicHealth Agency of Canada (PHAC).Three well-established, evidence-basedfederal programs were mentioned atthe Health Councils regional sessionsas having a strong, positive impacton the lives of Aboriginal women andchildren in their communities. Theseprograms are outlined separatelybecause they are well-establishedbest practices.

The Canada Prenatal Nutrition

Program (CPNP)The Canada Prenatal and NutritionProgram, a broad-based fundingprogram that is locally implementedand community-based, is deliveredthrough the Public Health Agency ofCanada (PHAC).

For more than ten years, CPNP hashelped commun ities to promote publichealth and provide support to improvethe health and well-being of pregnantwomen, new mothers and babiesfacing challenging life circumstances.

The goal is to improve maternal andinfant nutritional health. Programclients include pregnant First Nationsand Inuit women, mothers of infants,and infants up to 12 months ofage who live on reserve or in Inuitcommunities, particularly thoseidentied as high risk. It also includesFirst Nations and Inuit womenof childbearing age on reserve andin Inuit communities.

There are currently 330 CPNP sites

serving close to 50,000 women in over2,000 communities across Canadaeach year. In addition, a separatestream of the program administeredthrough Health Canada serves Inuitand First Nation women livingon reserve.

CPNP lls a distinct gap in communities.Almost all sites (98 percent) reportthat they provide a unique service intheir community. Many of the other

available prenatal services do notmeet the needs of the CPNP targetpopulation.

9

Aboriginal Head StartThere are two types of AboriginalHead Start programs in Canada,which started in the 1990s: AboriginalHead Start On Reserve (AHSOR) forFirst Nations children on reserve, andAboriginal Head Start in Urban andNorthern Communities (AHSUNC) for First Nations, Inuit, and Mtischildren living in urban and northerncommunities.

Whether on or off reserve, AboriginalHead Start programs aim to provideAboriginal children with a positivesense of themselves and a desire for

learning. These early interventionprograms support the spiritual,emotional, intellectual and physicaldevelopment of Aboriginal children,while also supporting their parents andguardians as their primary teachers.They address general health c oncernsin vulnerable populations and workto benet the health, well-being,and social development of Aboriginalchildren.

provincially or territorially insured services are notreadily available, the Government of Canadaprovides on-reserve primary and emergency careservices.

Non-Insured Health Benets are also provided to

approximately , eligible First Nationsand Inuit people. Coverage includes a speciedrange of medical goods and services (such asprescription drugs, vision care, dental services,medical supplies and equipment, and medicaltransportation) when these benets are notprovided through private or provincial/territorialhealth insurance plans.


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Summary pointsThe Health Council asked the question: If Canadawants to improve the health status of Aboriginalchildren as one way to reduce health disparities,what promising practices around maternal andchild health need to be either advanced or developed?

Through the regional sessions, we heard thatAboriginal maternal and child health programmingis crucial in addressing health disparities, reducinginequities, and improving health outcomes forFirst Nations, Inuit, and Mtis communities andindividuals. Moreover, there are common elementsthat characterize service models, programs,policies, and other initiatives as promising. Inone way or another, the practices outlined byparticipants are having a positive impact. To go back to the Health Councils denition for thisproject, these practices are:d

acknowledged to positively advance Aboriginalhealth status;

inclusive of the interests and experiences ofmany;

valued and supported by relevant stakeholders; well known and/or have a history of success; adaptive, recognizing the importance of

community context for successful implementa-tion; and

ideally they are evaluated.We also heard from participants that thesepractices are not without challenges. While thefederal government, provinces, territories, regionalhealth authorities, Aboriginal leaders, communitypartners and others have made great stridesin developing promising practices, participantsoverriding message was that the landscapeon which the promising practices are occurringis fractured, for essentially three reasons:

. While many federal programs are paving the way for success, the perception on the ground isthat there is no comprehensive, long-term,coordinated and concerted approach to servicedelivery, which is needed to ll gaps remainingin many First Nations and Inuit communities orto address gaps faced by Mtis people. Programssuch as Maternal and Child Health, the CanadaPrenatal Nutrition Program, and AboriginalHead Start result in improved outcomes formothers, infants, and young children andare incorporating many of the common featuresof promising practices. Yet not all Aboriginalpeople share in the advantages offered by theseprograms.

. Participants said that the level of complexityinvolved in the various funding arrangementsseverely limited opportunities for suc

Understanding and Improving Aboriginal Maternal and Child Health in Canada: Conversations about...

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