February 26, 1998

To: Budget Committee

Children=s Action Committee

Community and Neighbourhood Services Committee

From: City Clerk

Subject: Current Gaps in Public Health Services for Children

Recommendation:

The Board of Health on February 23, 1998 requested that the report (February 11, 1998) from the Acting Medical Officer of Health which identified current gaps in public health services for children and families across the new City of Toronto, be forwarded to the Children Action Committee and the Community and Neighbourhood Services Committee for consideration, and to the Budget Committee with a request that the Acting Medical Officer of Health report to that Committee with the amount of funding required.

The Board of Health on February 23, 1998, had before it a report (February 11, 1998) from the Acting Medical Officer of Health respecting current gaps in public health services for children and families.

The Board of Health also had before it the following communications respecting the aforementioned report:

The Board also received the foregoing report from the Acting Medical Officer of Health and decided to take into account the issues and needs raised therein when making decisions regarding the 1998 budget

City Clerk

Item No. 6

Attachment

February 11, 1998

cc: Acting Medical Officer of Health

To: Board of Health

From: Dr. Sheela Basrur, Acting Medical Officer of Health

Subject: Current Gaps in Public Health Services for Children

At a meeting on January 16, 1998 the Community and Neighbourhood Services Committee directed that the Acting Medical Officer of Health be requested to identify current gaps in public health services for children and families across the new City of Toronto and report thereon to the Children=s Action Committee, Interim Board of Health and Community and Neighbourhood Services Committee.

Recommendations:

It is recommended that:

(1) this report be received for information; and

(2) the Board of Health take into account the issues and needs raised in this report when making decisions regarding the 1998 budget; and

(3) this report be forwarded to the Children=s Action Committee for consideration; and

(4) this report be forwarded to the Community and Neighbourhood Services Committee for consideration; and

(5) this report be forwarded to the Budget Committee for approval of funds.

Background:

Children=s health has been a longstanding public health priority. Public Health is involved in a range of strategies undertaken by a variety of disciplines to meet the complex challenge of achieving optimal health for all Toronto=s children. These strategies include direct service through group and one-to-one approaches, as well as advocacy for healthy public policy, health promotion, coalition building, and community capacity building through community development and grants programs.

Discussion:

This report has a primary focus on group and one-to-one strategies and includes services that target all children and families and services that target those children and families that are high risk. The following questions are addressed; What do children need to grow up healthy? What are the public health services that address these needs? What are the current gaps in these services? Appendix 1 identifies some specific public health services and provides a summarized response to these questions.

The report focuses on gaps in services to very young children for good reason. It is becoming increasingly clear that public health services need to focus on prevention and intervention early in the life cycle. Until recently, neuroscience assumed that an individual=s brain structure was genetically predetermined. Science has now found that human development depends on an interaction between our genetic endowment and our early experiences. Ninety percent of brain development occurs in the first three years of life and early experiences have a decisive affect on the structure and organization of the brain. These early experiences have a long lasting impact on how individuals develop, their capacity to regulate their emotions, and their ability to learn.

There is no question that prevention and early intervention is a cost effective and appropriate use of resources. The literature has shown that it is far more effective and far less costly to promote healthy development in young children than to wait until their development is adversely affected. AIt is now clear that the window of opportunity for full emotional and cognitive development remain open only until age two or three, so that the potential for success - in school and in life - may be severely compromised by the first day of kindergarten@. (Steinhauer, 1996)

In order for children to grow up healthy and reach their full developmental potential, children need;

1. Healthy Birth Outcome

To get off to a good start the newborn needs a healthy birth outcome. Many factors contribute to a healthy birth outcome such as healthy choices before pregnancy, a healthy pregnancy, a safe labour and delivery and the absence of congenital birth defects. We know that public health services can make a difference by their influence on the following four healthy birth outcomes: a birth weight of at least 2500 grams, a gestation period of no less than 38 weeks, the absence of neural tube defect, and the absence of the effects of drugs (eg. Fetal Alcohol Syndrome).

Low birth weight poses a significant threat to a child=s health. Babies born too small are more likely to die as newborns and as they grow up are more likely to have health problems and developmental delays. The estimated low birth weight rate for Toronto was 6.7% in 1994 and 1995; the rate for the province was 5.9%. This means that 2352 low birth weight babies were born in our City in 1995.

Our reproductive health services are targeted to influence these particular birth outcomes. Best practices indicate the we must ensure prenatal classes are available to the general population. Our prenatal classes are offered free to all women early in their first pregnancy. Several hospitals in Toronto also offer prenatal classes but at a cost to the client ranging from $80. to $200. Furthermore, classes in hospitals are generally offered late in the pregnancy and focus on issues related to labour and delivery. Public Health prenatal classes are provided early in the pregnancy, a time when changes in the health practices of the mother can impact on healthy birth outcomes.

Our high risk services to pregnant women include both one-to-one and group strategies. Poor birth outcomes are much more prevalent in women with socio economic risk factors. In low income neighbourhoods, some ethnocultural communities, and some high risk groups, the low birth weight rate among singleton births is 8% - 20% compared with less than 4% in high income neighbourhoods and other ethnocultural communities. In 1995, 99 babies were born with evidence of prenatal drug exposure, 9 times more than in 1986. Many more go undetected and in the case of alcohol may not be apparent in infancy. Best practices suggest that high risk pregnancy support programs should provide education, one-to-one support, and nutrition supplementation.

Current Gaps:

Across the City we reach about 1 in 5 of the women who are having their first baby. In 1995, there were 16,370 first births (or 47% of all births). This limited accessibility to our prenatal classes is in part due to the large numbers of pregnant women who cannot access the classes due to language barriers. Our classes in languages other than English are limited. Secondly, limited accessibility results from the limited availability of our classes, both by the number of classes and the location of the classes.

Our high risk pregnancy support programs reach a very small percentage of the population that could benefit from these programs. For example, one program that meets best practices is Healthiest Baby Possible. However this particular program is not available across the City and is estimated to reach only 10% of the women with greatest potential to benefit.

Gaps also exist in our health promotion and advocacy strategies particularly in the area of preconception health. For example, there is a need for public awareness campaigns about the importance of folic acid supplements in preventing neural tube defects.

2. Healthy Early Transition

Mother and baby need a healthy early transition during the first 28 days of life. Public health services are designed to support breastfeeding, reduce infant readmissions for dehydration and jaundice, and build parenting skills. A number of partnership models for community-based breastfeeding clinics operate across the City. A study to evaluate the effects of early maternal and newborn discharge found Athat early discharge was safe and satisfying when a flexible, planned system of follow-up for all mothers was in place and community/home support emphasized@. (Ministry of Health, 1993). Three different models are in place for early post partum discharges and are currently being studied. These models ensure contact with the family within 24-48 hours of discharge. Although the first few days of life are critical, the vulnerability of mother and newborn extends throughout the first 28 days of life. Services that support breastfeeding and parenting skills are provided. Information, consultation, referral and links to community resources are available to new parents through our phone lines.

Current Gaps:

The Metropolitan Toronto District Health Council has recommended Athat a minimum of one home visit within the first 24-48 hours of discharge be offered to all mothers and that the visit be conducted by a professional (i.e., nurse) who is skilled in postpartum and breastfeeding assessment and teaching@. (MTDHC,1997). At the present time, public health is the most appropriate agency to provide this service because of the training and experience of our public health nurses. To do so would require transfer of funds from the hospital sector to the Public Health sector. Currently this type of follow-up is only available for mothers who deliver at St. Joseph=s Health Centre and Toronto Hospital.

Many new mothers in the City must feel at a loss in terms of who to call for help if they are experiencing problems breastfeeding their infants. Public health services as well as hospital and community services are uncoordinated and inconsistently available across the City. This gap in services is demonstrated by a recent study that reveals that more than 14% of mothers stop breastfeeding before their baby is 28 days old, not because they have the desire to stop but because they have problems or concerns that they were unable to resolve. (North York Public Health, 1994). Public Health phone lines have limited hours leaving a gap in service during evenings, nights, and weekends.

3. Nurturing Environment

Children need a nurturing environment that promotes healthy growth and development. Public health services can make a difference by impacting on the following components of a nurturing environment: the family=s capacity to parent, the development of secure infant attachment, a stimulating environment, and social networks of support. Best practices suggest that parenting groups for the general population be provided for parents at Atransition@ times, including infancy, 18 months, school entry, and preteen.

To reach high risk populations, one-to-one and group programs must be available. It is estimated that 1 in 3 of Toronto=s children are living in poverty. As many as 1 in 4 children is in a single parent family and more than half of these families have low incomes. The newly initiated provincial program, Healthy Babies, Healthy Children, will provide one-to-one lay home visiting to this high risk population.

Current Gaps:

Our group parenting programs for the whole population are limited across the new City. Limited accessibility results from too few available groups and language service barriers that limit access. Availability of parenting programs is also limited through other service providers.

Group and one-to-one services for high risk families are extremely limited despite the huge potential to benefit. Healthy Babies, Healthy Children is recognized to be under funded. Furthermore, the Assistant Deputy Minister stated that, AHealthy Babies, Healthy Children needs to be embedded in a system of supports and services@. (Jessica Hill, Feb.1998). With the implementation of the screening component of Healthy Babies, Healthy Children of all newborns across the new City, our current service gaps will become alarmingly clear.

4. Healthy and Safe Environment

Children need a healthy and safe environment, whether they are in their home, their playground, their day care centre, or in school. Public health services address a wide range of needs in this area including the need for adequate nutritious food, safety, immunization, dental care, and healthy lifestyle practices. A broad range of public health services address the need for a healthy and safe environment, many of which are identified in Appendix 1. As well, a great many of our health promotion and advocacy strategies are directed toward this need.

Current Gaps:

There are gaps across the City both in dental screening and in dental treatment for high risk children. Gaps exist in the areas of physical activity and nutrition as indicated by the Report Card on Children=s Health released last week. Population based injury prevention programs are limited.

Scientific evidence is emerging that suggests that children are more vulnerable to environmental hazards than adults. Consequently, environmental protection and health promotion initiatives need to develop a new focus on children. There is a need to make parents and child caregivers more aware of environmental conditions in the home and community that could adversely affect child health so that parents and caregivers could reduce or avoid these exposures.

Emerging Issues:

Emerging issues that need to be considered in more depth include the number of teen mothers, particularly those who are homeless; the absence of services that address the needs of children in informal day care; and the absence of programs that promote the parenting capacity of fathers in light of the number of families where both parents work. These emerging and already existing issues make it clear that the gaps exist in the City. During the transition discussions specific to public health services, it was identified that to meet the needs of young children and mothers across the City would require a minimum of $5.5 million additional funding. This money, augmenting the Provincial Healthy Babies/Healthy Children Program and already existing Public Health programs, would allow for pre and post-natal lay home visiting, nursing and nutritional services (including the Healthiest Babies Possible program) and for dental treatment to those unable to access services elsewhere. This funding would ensure equitable service access and delivery in meeting the needs of young children and mothers across the City.

Conclusions:

Public health services, such as our Prenatal Classes and Infant Parenting Groups, that are targeted to whole populations may reach as many as 20% of children and families. However, our services targeted to high risk populations, based on available information, are estimated to reach less than 20% of high risk children and families, despite the increasing numbers that have the potential to benefit from these services. Gaps in service accessibility result primarily from the limited number of services available across the City and the language and cultural service barriers that limit access.

Dr. Jack Lee, Regional Director, Toronto Office

Tel: 392-7467

Fax: 392-0713

Sheela Basrur, MD, MHSc, FRCPC

Acting Medical Officer of Health

References

2. MTDHC. Postnatal Care: Care and Support of the other and Newborn 0-28 days. December 1997.

4. North York Public Health. Survey of Infant Feeding Practices in North York. 1994