Symposium on "parental education" at the ICCH17.

This symposium report provides a brief overview of the six programmes and studies on parental education and maternal health services within the circumpolar region presented in the symposium "parental education" at the 17th International Congress of Circumpolar Health in Copenhagen, Denmark, August 2018.

Background

In mid-August 2018, close to 400 scientists, policymakers, practitioners, Indigenous representatives and students from all the Arctic countries gathered in Copenhagen, Denmark, for the 17th International Congress on Circumpolar Health (ICCH17). The ICCH is initiated and supported by the International Union for Circumpolar Health, and the conference represents the largest scientific meeting on circumpolar health worldwide. Since 1967, the ICCH conferences are held every third year in different locations in the Arctic region. With a tightly packed programme, various topics were addressed in keynotes, oral and poster presentations, workshops and side-meetings. The various health topics included environmental health, genetics, chronic and infectious diseases, ageing, mental health, cultural sensitivity, health-care systems and maternal health in the Arctic [1].

The Centre for Public Health in Greenland at the National Institute of Public Health (SDU, Denmark) initiated the symposium “parental education” at the ICCH17. The aim was to create a forum for the exchange of experiences and create awareness of the different existing Arctic initiatives aiming to enhance parenting skills and secure newborns a good and healthy start. Six abstracts from Greenland, Canada and Norway were orally presented at this symposium. The six presented abstracts varied widely in their subject matter, epistemologies, methodologies and methods. The content of each presentation is outlined below.

1. Uptake and impact of prenatal education in Northwestern Ontario: mother’s perspective

From Northwestern Ontario (Canada), Møller and Sameshima presented their research on mothers’ perspectives on the uptake and impact of prenatal education [2]. Prenatal education programmes aim to provide pregnant women and their supports with the information and skills they need to improve pregnancy and birth outcomes as well as information on early parenting. Earlier studies conducted in Canada show that Indigenous women, immigrant and refugee women, younger women and women who have lower education and income report poorer maternity experiences compared to other Canadian women. Furthermore, they are less likely to access prenatal care and education [3,4]. Based on the principle of equity in access to quality maternal care, Møller et al. conducted an interdisciplinary qualitative project. In-depth interviews with 40 women (18 Indigenous, 9 immigrant or refugee, 13 Euro-Canadian) from Sioux Lookout, Kenora and Thunder Bay in Ontario (Canada) were conducted with the aim to explore women’s experiences regarding accessing the desired pre-, peri- and postnatal knowledge and education.

The majority of the Indigenous (66%) and immigrant/refugee (70%) mothers did not participate in perinatal education, whereas the majority of the Euro-Canadian (76%) mothers did. While prenatal education was thought to be important and empowering for all women, inequities in availability and accessibility of programmes were reported. Single mothers, younger and older mothers, and mothers living in difficult social circumstances expressed concerns about “not fitting in” or feeling stigmatised, which prevented them from accessing prenatal education programmes, if they were available. For many Indigenous mothers, barriers to prenatal education included limited information about available services and a lack of programmes available in remote communities. Moreover, transportation and childcare support are a challenge when trying to access programmes distant from their communities. Immigrant and refugee mothers stated to not have received information about the availability of programmes or language barriers hindered them in participating. Midwifery supported pregnancies and births contributed to higher satisfaction with the availability and comprehensiveness of received information. Mothers, who have participated in prenatal programmes, pointed out the desire for earlier and more personalised prenatal education and need for more information on (i) mental health challenges and support, (ii) pregnancy and birthing complications, (iii) pain management options, (iv) breastfeeding and (v) early parenting. In addition, some Indigenous mothers wanted more information about traditional cultural practices within pregnancy and birth.

Overall, mothers desired to attend prenatal education programmes, but the accessibility in remote communities needs to be improved. Mothers suggested increased individualised support, earlier enrolment and an added focus on mental health through the pre- and postnatal periods. As recommended by the WHO [5], these are aspects that would optimise pre-, peri- and postnatal experiences for many women.

2. Learning from mothers and grandmothers about breastfeeding in the Northwest Territories Canada

In the Northwest Territories of Canada, Moffitt and colleagues focused in their study on the traditional knowledge that mothers and grandmothers have in breastfeeding, a central aspect to mothering [6]. Traditional practices of mothering are important to the identities of Indigenous women, families and their communities. Traditional knowledge shared by Indigenous Elders is deeply respected in Canada’s North and is alive in stories shared by grandmothers and great-grandmothers. Unfortunately, women’s acquisition of breastfeeding knowledge and cultural practices were interrupted by the impact of colonisation, patriarchy, residential schooling and subsequent loss of knowledge transmission between Elders and youth. The aim of this study was to generate knowledge that would guide health promotion efforts targeting territorial mothers and be inclusive of traditional knowledge. Moffitt et al. gathered findings about infant feeding practices from 49 grandmothers attending sharing circles in 4 regions of the Northwest Territories (Yellowknife, Inuvik, Tulita, Hay River and Fort Smith) and conducted semi-structured interviews with 24 new mothers in the fall of 2017.

Traditional knowledge was gathered from grandmothers under three themes: (i) mothering with resilience and resourcefulness, (ii) surviving hardships and (iii) rekindling past practices. Infant feeding practices were illuminated from new mothers, and a video was created with key messages from grandmothers and mothers [7]. Additionally, an infographic was developed as an inspiring information sheet for new mothers (see Figure 1). Community grandmothers are well positioned to be role models in supporting women in feeding their babies and addressing current mothering issues that occur in their communities. They wish to reclaim their roles and share their wisdom, support and advice to new mothers. Their words hold powerful messages for new mothers.

Figure 1.

Information sheet on traditional breastfeeding for mothers in NWT. Copyright Moffitt, PM, et al

3. Inunnguiniq parenting programme: a made-in-Nunavut programme based on Inuit knowledge

Tagalik presented the Inunnguiniq Parenting Programme from Nunavut (Canada), which was developed, piloted and implemented by the Qaujigiartiit Health Research Centre [8]. The programme was initiated based on several conducted public engagement sessions in Nunavut communities, where the need for parenting support was a universal theme. Conducted studies investigating children’s and youth’s well-being, and the philosophy and values told by Elders built the foundation of the Inunnguiniq parenting programme. Inunnguiniq, meaning “making a capable human being”, is the intentional process for childrearing among Inuit in Nunavut. Experiential learning from a young age helps build their skills, knowledge and capacity on the land and relationships with other people. The cultural expectation is that every child is capable to live a good life, contributing to working for the common good, helping others and making improvements for those to come.

The goals of the programme are to (i) bring back Inuit parenting teachings and practices in ways that work today, (ii) recognise the need for healing from the colonial past and the trauma which resulted in breaking the system for inunnguiniq and (iii) rebuild the strengths of Inuit parenting and bring the heart-centred inunnguiniq practices back into parenting in Nunavut today. This evidence-based parenting programme was launched in 2015 after piloting it in 10 communities, revising and finally re-piloting it in four communities. The programme is being evaluated and updated on an ongoing basis in order to remain responsive to the needs of Nunavut parents.

4. Early prevention in Greenland: MANU 0–2 years, a parent education programme

In Greenland, a parent education programme “MANU 0–2 years” was launched between 2017 and 2018, which was presented by the project coordinator Kuhn at the ICCH17 [9]. MANU stands for Meeraq Angajoqqaat NUannaarneq, meaning “child and parent’s good life”. The programme’s concept builds on the theories of mentalisation, attachment theory, emotional regulation, and children’s health and development. It is a universal parent education programme addressing both the mother and the father.

On the grounds of the social challenges many Greenlanders face, MANU focuses on strengthening the skills of parents through positive parenting in order to also support those who grew up in a more unstable home. The Greenland health survey from 2014 reported that 66% of the adult population grew up in a home with alcohol-related problems or had been exposed to violence or sexual assault [10]. In the programme, parents are asked to reflect on their own childhood and are then invited to discuss their thoughts and ideas with their partner and other participating parents. One exercise, for example, is to discuss what the upbringing of their own child should look like and how the parents together wish to achieve that.

A large effort has been put into the concrete pedagogical materials and adult education concepts in the development of the programme. Midwives and public health nurses are the primary professionals receiving a three-day training for the programme before they implement the programme in their region or local community. The primary author of this communication piece will follow the implementation process of MANU in her PhD project from 2019 to 2022.

5.1. Arctic model of the first 1,000 days – a (under development) parent education programme in Sápmi Norway

During the symposium, Kvernmo and Nilsen briefly presented their current collaboration with the Australian project “The First 1000 Days Australia” from Melbourne University [11]. On the foundation of the scientific evidence provided by the 2008 Lancet Series [12], the first 1,000 days of life, spanning between conception and one’s second birthday, has proven to be a unique period to lay the optimal base for health, growth and neurodevelopment for life. The Australian model is Indigenous-led and supported. The concept of the model and the Indigenous involvement are being applied in the development of the Arctic model, where currently the focus is expected to be placed on the Sami language instead of nutrition as it is in the Australian model.

5.2. The SamBa study: growing up in the Arctic – a longitudinal study of early childhood development and health in Indigenous and non-Indigenous children

Nilsen presented the ongoing longitudinal study on early childhood development and health of ethnic diverse children in the Arctic part of Norway [13]. The study is called SamBa, which stands for Samiske Barn meaning Sami child. The aim of the study is to gain insights into how the antenatal and early lives of Sami and Arctic children affect later outcomes. This will be done by combining data from the Norwegian Mother and Child Cohort Study (MoBa) with a supplementary data collection based on community-based participatory methods. Additionally, this study will collaborate with the “Longitudinal Study on Indigenous Children (LSIC) in Australia”. This is the first project investigating social and cultural determinants of Indigenous child development and health across Indigenous populations.

Approximately 5,700 children from North Norway participated in the MoBa study, including 487 Sami children. First, the SamBa study will examine the influence of peri- and postnatal maternal health and pregnancy length on children’s developmental milestones (motor, social and language development) and well-being at the age of 18 and 36 months. Thereafter, Sami parents and their controls will receive a questionnaire on Sami ethnicity, language use and identity as well as a variety of cultural determinants. The questionnaire will be developed in close collaboration with a reference group consisting of Sami parents/grandparents/great-grandparents and health-care workers. Finally, data from both collections will be combined in order to examine the effects of social and cultural determinants on early developmental trajectories and well-being in Sami and non-Sami children, as well as shared determinants across groups. Preliminary results from the reference group meetings were briefly presented in the symposium.

6. Selecting performance indicators for maternity care in a circumpolar context: a modified Delphi approach

Rich presented her research on the selection of performance indicators for maternity care in a circumpolar context [14]. This work was conducted as part of a thesis project at the Institute for Health Policy, Management and Evaluation, University of Toronto. Performance measurement has become an increasingly popular tool in the pursuit of health-care quality, accountability and value for money. In circumpolar regions, indicators that are aligned with national strategies may ignore or even conflict with the priorities and values of Northern, remote or Indigenous populations. For circumpolar maternity care, the frequent practice of routine evacuation for birth highlights a potential conflict between the necessity to ensure patient safety and the importance of delivering locally responsive services. Contextually appropriate performance measurement is an important step in resolving this conflict. The objective of this study was to select performance indicators that are relevant to maternity care systems in circumpolar regions.

It was supported by the Canadian Institutes of Health Research team grant in community-based primary health care (No. TT6-128271). Community engagement was supported by the Canadian Foundation for Women’s Health (Dawn Walker Grant) and the Canadian Institutes of Health Research – Strategy for Patient-Oriented Research Patient Engagement – collaboration grant (No. 201511PEG).

A scoping review generated a working list of indicators [14]. Fourteen circumpolar maternity care experts then participated in a two-round modified Delphi consensus process. Participants rated each of the 62 proposed indicators according to importance, circumpolar relevance, validity and reliability. Agreement was measured using Cronbach’s alpha. The scoping review included 26 publications from which 81 unique performance indicators were identified. Sixty-two of these indicators were presented to the Delphi panel for evaluation. Eleven indicators met criteria for importance, circumpolar relevance, validity and reliability. Twenty-nine additional indicators were identified for further consideration. Three themes were identified through the Delphi process: social determinants of health, cultural competency and travel for care. The results suggest that the Pan-Canadian maternity care indicators are not appropriate for the circumpolar north, rather indicators that reflect local and regional priorities should be considered. While most circumpolar health systems engage in performance reporting for maternity care, efforts are heterogeneous, and indicators do not necessarily reflect local priorities and challenges. A modified Delphi approach was effective in selecting contextually appropriate indicators for circumpolar maternity systems.

Concluding remarks

The presentations of the “parental education“ symposium at the ICCH17 led to a positive and lively discussion among presenters and listeners about the positive influence parental education programmes can have in the first 1,000 days of childhood. Access to and quality of services were common themes in this discussion. The group also discussed the importance of Indigenous knowledge and contributions of Elders and grandparents.

In addition to discussing the content of each presentation, the symposium participants also had an opportunity to consider the various research approaches used. While a detailed critique of each project is beyond the scope of this communication, the symposium attendees recognised the value of engaging in participatory and community-driven research, the use of trauma-informed approaches and the development of culturally relevant programmes.

The symposium also reached its aim of providing a forum for the exchange of knowledge and experiences across the circumpolar region. Ruth Montgomery-Andersen initiated the establishment of the first Circumpolar Maternal and Child Health Working Group (MCHWG) during the conference. The MCHWG vision is to promote and advocate for a human rights-based approach to improving health outcomes and equity in the circumpolar region [15]. These approaches are underpinned by the United Nations’ Declaration of Human Rights [16], The Convention on the Rights of the Child [17] and The Rights of Indigenous Peoples [18]. The Group aspires to nurture collaborative relationships both within the groups as well as across and beyond the region; offer support to maternal and health projects, advocate for ethical collaborations with Indigenous people and their families; and produce scientific articles that can contribute towards improving the health and well-being of Arctic mothers, children and families.