Marjaana Pelkonen, 29.04.2016, Reproductive, maternity and child health in primary healthcare in Finland

1. Maternity and child health care in
Finland
Tuovi Hakulinen, Research Manager, PhD, Adjunct
Professor
Marjaana Pelkonen, Ministerial Advisor, PhD, Ministry
of Social Affairs and Health

2. A long history of Finnish maternity and child
health care
• First maternity and child health clinics were established in
1920’s
• Act on Child Care Clinics in 1944
– Municipalities had a legal obligation to provide maternity and
child health clinics services
9.5.2016 Tuovi Hakulinen 2

3. Keys indicators: Maternal deaths are rare
• Maternal mortality: 2.8 deaths per year and 4.8 per
100 000 live births in 2005–2010
9.5.2016 Tuovi Hakulinen 3

4. Key indicators: Infant deaths are rare
• Infant mortality rate is among the lowest in the
world; 1.8 per 1,000 live births in 2013
9.5.2016 Tuovi Hakulinen 4

5. Family policy in Finland
• The Aim
• To create a safe environment for children to grow up
and to provide parents with the material and
psychological means to have and raise children
• Support for families
1. Services: health care, social welfare, education
2. Financial support
– Maternity grant: maternity package or cash lump sum
– Maternity, paternity and parental allowances
– Child benefits, housing support etc.
3. Family leave system
9.5.2016 Tuovi Hakulinen 5

6. Primary care services for families with
children
9.5.2016 Tuovi Hakulinen 6
Day care
Primary
education
Secondary
education
University
University of
Applied sciences
Maternity
clinics Child health
clinics
Student health careSchool health
care
Pre-
primary
education
Birth 7 years6 years 16 years 19 years

7. Guidance and provision of public health
services
• Guidance: the Ministry of Social Affairs and
Health
• Public health care services
– Primary health care and specialized hospital care
• Responsibility for organising primary health
services: municipalities
• Primary health care in health centres
– 157 health centres in 2014
• Maternity and child health clinics
• School and student health care
• Dental care
• Medical care, Home nursing etc.
Tuovi Hakulinen 79.5.2016

8. New legislation on maternity and child
health care
• The Health Care Act 1326/2010
• Government Decree 338/2011 on maternity and
child health clinic services, school and student
health services and preventive oral health services
for children and youth
• Child Welfare Act 417/2007
• Social Welfare Act 1301/2014
– Health promotion and empowerment
– Early intervention: targeted support to those who
need it
– Services should be equal in quality and take the needs
of families at large into account
Tuovi Hakulinen 89.5.2016

9. Guiding and supervision
• National Institute for Health and Welfare (THL)
– Supports municipalities and monitors the
implementation of legislation
• National Supervisory Authority for Welfare and
Health
– Supervises health centres and implementation of
legislation
• Regional State Administrative Agencies
– Supervise services provided in their respective
districts
Tuovi Hakulinen 99.5.2016

10. National recommendations
• THL issued new national
recommendations for maternity
clinics (2013)
• Extensive health
examinations – A
guidebook for
staff (THL 2013)
Tuovi Hakulinen 109.5.2016

11. Funding of public health services
• The health care system is mostly funded by
taxation levied by the state and the local
authorities
• The sate supports municipal service provision
by means of central government transfers to
local government
9.5.2016 Tuovi Hakulinen 11

12. Access to the primary health services
• Free of charge within easy reach of clients in
every municipality
• Universal for all social groups, voluntary
• Widely used and accepted regardless of social
class
• Maternity clinics
– 99,8 % of families use these services
• Child health clinics
– 99,5 % of families use these services
Tuovi Hakulinen 129.5.2016

13. Number of births, children and adolescents
• Births per year: around 60 000
 Maternity health clinic services
• Children under school age (0-6 years): 420 000
Child health clinic services
• School aged children (7-15 years): 520 000/
primary school
School health care services
• Students (16-18 years): 370 000/General Upper
Secondary education/Vocational Upper Sec. Ed.
Student health care services
• Students (over 19 years): 300 000, University
education/Polytechnic education
– Student health care services
9.5.2016 Tuovi Hakulinen 13

14. Current challenges in women’s health
and well-being, some examples
• Pregnancy in women over 35 years of age
– Increasing risk of gestational diabetes, miscarriage,
pre-term birth, hypertensive disorders of pregnancy
• In 2011 one third of all women having given birth
were overweight (BMI 25 or more) and 12 % were
obese (BMI> 30)
• In 2011 some 16 % of all women have smoked
during pregnancy
– Source: Nordic perinatal statistics 2012
9.5.2016 Tuovi Hakulinen 14

15. Current challenges in children’s health
• Finnish children and families are doing well
• Psychosocial and behavioural problems,
learning difficulties and obesity
• Parental mental illness, alcohol abuse,
domestic violence, problems in couple
relationships and unemployment
Severe impacts on children’s health and
wellbeing
• Inequalities in children’s health
9.5.2016 Tuovi Hakulinen 15

16. Maternity and child health care services
• Goals
– to promote the health and wellbeing of the
pregnant mothers and their families/children and
their parents and to prevent illnesses
– to reduce health inequalities between population
groups
• Objectives
– to monitor and support healthy pregnancy/growth
and development of children and to empower
parents in caring and rearing of their children
– to identify any need for special support as early as
possible
– to provide support and assistance and to refer
clients to examinations and treatment when needed
9.5.2016 Tuovi Hakulinen 16

17. Core personnel
• Core team in maternity and child health clinics
– Public health nurses (or midwives in maternity
clinics)
– Physicians
– Family workers (social work)
• Other professionals in health centres
– Psychologists, physiotherapists, speech therapists,
nutritionists, dentists
• Multiprofessional and multisectoral
collaboration within the municipality
– Early education (day care)
– Social welfare: family work, home aid, child
protection, family counselling
– Specialized health care
Tuovi Hakulinen 179.5.2016

18. The purpose of maternity clinics
• To secure the welfare of pregnant mothers and
unborn children and
• To promote mental and psychological welfare and
health habits of the whole family
• Services include health examinations, counselling,
home visits and family training
– Mothers are screened for hepatitis B, syphilis, HIV
– Ultrasound scans are offered
• Close cooperation with maternity hospitals and
outpatients maternity clinics
Tuovi Hakulinen 189.5.2016

19. At least 8-9 visits during the normal
course of a pregnancy and 2 after the
delivery
9.5.2016 Tuovi Hakulinen 19

20. Scheduled appointments at maternity clinics
Appointments Parity Regular health examinations Time*
6.–8. wk P, M First contact: telephone or face to face assessment of the need
of support
15 min
8.–10. wk P, M PHN (public health nurse) or midwife 1 h 30 min
13.–18. wk P, M Extensive health examination: PHN or midwife 1 h 30 min
13.–18. wk P, M Extensive health examination: Doctor 30 min
22.–24. wk P, M PHN or midwife 30 min
26.–28. wk P PHN or midwife 30 min
30.–32. wk P, M PHN or midwife
Home visit for the first-time parents
30 min or
2 h 30 min
35.–36. wk P, M Doctor 30 min
37.–41. wk P, M PHN or midwife - Visit fortnightly or more when needed 30 min
Delivery
1.–7. d after
discharge
P, M PHN or midwife: visit to the clinic or home visit 60 min
2 h 30 min
5.–12. wk P, M Postpartum checkup: doctor or PHN or midwife 30 min
9.5.2016 Tuovi Hakulinen 20

21. The purpose of child health clinics
• To promote the health of children and the whole
family
• To monitor and support the physical, psychological
and social development of the child as well as the
parents’ resources and coping
• Services include health examinations, counselling,
home visits and parent groups
– Immunization of children in accordance with the
national vaccination programme
– Observations of growth in height and weight,
acuity of vision, hearing, speech development,
psychomotor skills, interaction with parents
21Tuovi Hakulinen9.5.2016

22. At least 9 health visits during the first year
of an infant’s life and 6 between the ages of
1 and 6
Tuovi Hakulinen 229.5.2016

23. Scheduled appoinments at child health clinic
Appointments Regular health examinations and actors
1-4 wk PHN (public health nurse)
4-6 wk Doctor
2 mth PHN
3 mth PHN
4 mth Extensive health examination: PHN and doctor, jointly or separately
5 mth PHN
6 mth PHN
8 mth Doctor
12 mth PHN
18 mth Extensive health examination: PHN and doctor, jointly or separately
2 yrs PHN
3 yrs PHN
4 yrs Extensive health examination: PHN and doctor, jointly or separately
5 yrs PHN
6 yrs PHN
9.5.2016 Tuovi Hakulinen 23

24. Finnish national vaccination programme
All population
Vaccine Recommended age
Rota 2 months
DTaP-IPV-Hib
+ Rota, PCV
3 months
DTaP-IPV-Hib
+ Rota, PCV
5 months
DTaP-IPV-
Hib, PCV
12 months
MMR 12-18 months
HPV girls 11-12 y, catch up 13-15 y
Influenza 6-35 months (annually)
DTaP-IPV 4 years
MMR 6 years
dtap 14-15 years
dT adults, every 10 years
Risk groups
Vaccine At the earliest at age
BCG < 1 week
HBV 0 d
HAV 12 months
Influenza 6 months
TBE * 12 months
PCV 3 months
PPV 2 years
*Residents of Åland temporarily, 2006-2010
Tuovi Hakulinen9.5.2016 24

25. Extensive health examinations
• Assessment of the health and well-being of
parents and the entire family, introducing earlier
support and strengthening empowerment of
families
• At least one extensive health examination for
each family expecting a baby
• Three extensive examinations for child-rearing
families
• At the ages of 4 and 18 months and 4 years
• Both parents are invited along
• Jointly conducted by a PHN/midwife and a
phycisian
• Source: Government Decree 338/2011
9.5.2016 25Tuovi Hakulinen

26. Factors that increase well-being in children
and young people
• Safe and stable adults
• A good relationship with
parents
• A culture of care in
upbringing
• A lifestyle that
promotes health and
well-being
• Knowing that you can
cope
• Friends
• Predictability of
everyday life and
financial stability
• Parents' own well-being
• Good relationship
between parents
• Sufficient family
support network
• Time spent with the
family
9.5.2016 Tuovi Hakulinen 26
Source: Afifi & MacMillan 2011, Bell et al. 2013

27. The earlier the investment, the greater the
return
9.5.2016 Tuovi Hakulinen 27
Source: JJ Heckman 2008, 2009

28. Five main themes of assessment of
support needs in extensive health ex:s
• Parents’ health and wellbeing
– Major health problems, couple relationship, home
atmosphere
• Family members’ interaction
– Interaction of parents and children, child rearing
practices, security
• Living conditions and social support
– Parents’ income and employment, availability of
support
• Child’s health and wellbeing
• Siblings’ health and wellbeing
9.5.2016 Tuovi Hakulinen 28

29. Early identification of support needs
• Regular health visits and health counselling enable
early detection of needs for special support
• The nature of the relationship between the family
and PHN/midwife/physician: trust, collaboration
• Interviewing parents
• Taking up one’s worries
• Use of questionnaire forms e.g.
– AUDIT-test, EPDS, Family resources, Domestic
violence
• Support should be provided without
delay
29Tuovi Hakulinen9.5.2016

30. Additional follow-up and support to those
who need it 1/2
• Indicators for extra visits and support during
pregnancy:
• Mother’s chronic diseases e.g.
– Asthma, mental health problems, diabetes
• Problems in pregnancy e.g.
– Risk for preterm birth, pre-eclampsia, gestational
diabetes, multiple pregnancy
• Family problems and concerns e.g.
• Domestic violence, substance misuse, mental health
• Pregnant mother is referred to a maternity
outpatient clinic when needed
• High-risk pregnancies and deliveries are taken
care in university and central hospitalsTuovi Hakulinen 309.5.2016

31. Additional follow-up and support to those
who need it 2/2
• Indicators for extra visits and support during child-
rearing stage:
• Concerns and problems of children e.g.
• Psychosocial problems, learning difficulties, ADHD,
overweight, obesity
• Concerns and problems of parents e.g.
• Mental health problems, alcohol abuse, domestic violence
• Extra visits to child health clinic, home visits, family
work, peer groups
• Multiprofessional work at health centre
• Consultations and further examinations in specialised
health care
Tuovi Hakulinen 319.5.2016

32. National follow-ups
• New regulations, follow-ups and supervision have
improved the functions of maternity and child health
clinics to better meet the needs of children and
families
9.5.2016 Tuovi Hakulinen 32
• Both PHNs and client families have reported that
extensive health examinations have been useful as
they have provided an opportunity to discuss issues
that would otherwise have gone unnoticed
• This allows responding to the child and family needs
earlier, and providing support to those in need
• Sources: Hakulinen-Viitanen et al. 2014, Lammi-Taskula & Karvonen
eds. 2014

33. Percentage of health centres (N=150) which
arranged extensive health examinations in line with
legislation
339.5.2016 Tuovi Hakulinen
2009: Ståhl & Saaristo 2011, 2011: Wiss et al. 2012, 2012: Hakulinen-Viitanen et al. 2014,
2013: Wiss et al. 2014

34. Conclusions and future challenges
• An issue
– Health promotion and prevention are public
priorities (e.g. Government programme) but not
always taken into account in municipal decision
making
• Investments in prevention are needed but
municipalities have economic difficulties due to
economic recession
9.5.2016 Tuovi Hakulinen 34

35. The reform of the social welfare and
healthcare service system
• There will be 18 autonomous regions in the country,
• These regions will be responisible for organising
health and social services in their area
• The changes are expected to bring substantial
savings to the public finance
Government’s new programme 2015-2018
• Programme to address reform in child and family
services
• Emphasis on promotion and prevention
• Participation
9.5.2016 Tuovi Hakulinen 35

36. Benefits for families with children by KELA
• Parents are entitled to maternity, paternity and
parental allowances
– when one has been covered by the Finnish social
security for at least 180 days just before the
estimated date of delivery
• See Social Insurance Institution (KELA)
http://www.kela.fi/web/en/families
• Maternity grant
– when pregnancy has lasted at least 154 days
– Certification on pegnancy is needed; given by
maternity clinic or medical doctor/private sector
– Cash maternity grant (140 €) OR maternity
package9.5.2016 Tuovi Hakulinen 36

37. Maternity package 2015 (KELA)
9.5.2016 Tuovi Hakulinen 37

38. Thank you very much!
9.5.2016 Tuovi Hakulinen 38
tuovi.hakulinen@thl.fi