Model of Health 2.0

Model of Health – Applied to Maternal and Newborn Care

Women’s health, specifically pre-, intra-, and postpartum care, has been the focus of the majority of my career. It has impacted me both personally and professionally in the city of Hamilton. I have seen firsthand where care has excelled and where care has lacked. For this week’s assignment, I chose to look at a multi-level model of health from a women’s health perspective and highlight some of the concerns around the reality pregnant women in my city are facing.

Like some of my classmates, I have turned to the Institute of Medicine’s model of health and applied it to obstetrical care, Figure 1 (Institute of Medicine, 2010, as cited in Galea, 2015).  I see this approach as an all-encompassing view of the factors and influence over the health of pregnant women from pre-conception to postpartum care.

Figure 1 (Institute of Medicine, 2010, as cited in Galea, 2015)

Individual 

The course of a pregnancy can vary from person to person, with both maternal and fetal factors influencing the outcome. Many women enter a pregnancy with pre-existing medical conditions, at an increased risk of carrying multiples, or with a known or unknown risk of genetic complications in their baby. Regardless of the unique set of circumstances, there will always be a need for a personal approach to care for each mother.

Neighbourhood, Community, and Wider Society 

In their article, Multimorbidity in Large Canadian Urban Centres: A Multilevel Analysis of Pooled 2015–2018 Cross-sectional Cycles of the Canadian Community Health Survey, Wilk et al. (Wilk, 2021) discuss multimorbidity in Canadian urban centres, acknowledging that the number of Canadians living with chronic conditions poses a significant burden on the healthcare system, as well as on individuals and their families. The study also found that being female increased the likelihood of having multimorbidity. Additionally, there is an inverse relationship between socioeconomic factors, as the onset of multimorbidity occurs earlier among individuals in more socially deprived groups. This suggests that women, especially those of childbearing age and with lower socioeconomic status, are at a disadvantage when it comes to health. This influence on the individual, in relation to the neighbourhood or community in which they reside, impacts their overall maternal health.

When cross-referenced with the City of Hamilton’s Public Health Status Report (2024), the story is the same. Being of childbearing age saw some of the highest rates of living in poverty (14% for those aged 18-24 years). Specific to breastfeeding, the highest rates of exclusive breastfeeding at two months, and the lowest rates of any formula use in hospital, were among caregivers with post-secondary education, incomes greater than $150,000, in a stable relationship, and who identified as white.  One-quarter of the population in Hamilton self-identifying as belonging to a racialized group. Rates of preterm births and low birth weights are higher among residents with lower incomes and lower education. At every turn, there is evidence to suggest that being of lower economic status puts women and their babies at a disadvantage.

Health Communication 

Access to health information has never been easier, but how accurate or helpful is that information? In their review, Improving Communication Between Health Professionals and Women in Maternity Care: A Structured Review, Rowe et al. (Rowe, 2002) determined that increased communication between women and their provider during the antenatal period has positive effects. Having more information from their provider about antenatal testing was valuable in reducing test anxiety. They also found that woman-held maternity records bring benefits to women in terms of their perceived involvement in and control over their care.

At HHS, we are expanding our MyChart capabilities so patients have increasing access to their own health information. We are strengthening the connection between this patient service and our in-house EMR in order for the flow of information to be smooth between the systems. Ideally, this will prompt increased conversation and connections between patients and their providers.

Health Care Delivery 

The American College of Obstetricians and Gynecologists (ACOG, 2019) agree that more can be done to improve the system of care for high-risk women at the facility and population levels. The ultimate goal of levels of maternal care is to reduce maternal morbidity and mortality, including existing disparities, by encouraging the growth and maturation of systems for the provision of risk-appropriate care specific to maternal health needs.

This approach is similarly supported in Ontario. The Provincial Council for Maternal and Child Health (PCMCH, 2022) has standard definitions for maternal and newborn levels of care. This is the standard used and understood by all maternal and newborn care centres and their related designation.  These definitions outline what the requirements are for risk, support, illness and intervention, skill level, and transfer for each organization. When this model is understood and followed by all delivery institutions, it ensures mothers and their babies are getting the care they need when and where they need it.

Determinants 

As discussed in a previous blog post, the determinants of health are not a set list of items; they vary depending on if you are following global, national or provincial perspectives. What is agreed upon, however, is that there are many elements influencing a person’s overall health.

From a Hamilton perspective, in 2023 public health took on two important aspects of work to address some of the gaps related to determinants of health in this city. They educated health professionals and organizations on the importance of prenatal screening for early identification of pregnant individuals at risk for poor mental health. Additionally, they introduced virtual breastfeeding sessions to reach those who experience challenges accessing in-person services (Hamilton Public Health, 2023). Two concrete examples of ways public health is taking action to address some of the challenges pregnant women in this city are facing.

There are, of course, many additional factors that can influence health before, during, and after a pregnancy. While there is understood to be universal healthcare in Canada that allows reasonable access to medically necessary health services, decisions around funding and services made at the provincial and regional level can greatly influence access to resources. As can location, access to transportation, education, and language. The findings in the articles reviewed could be used to inform local public health officials, acute care centres, and women’s health care providers about the realities of health for women of childbearing age in Hamilton. This could help them to better advocate for access to care and allocation of resources to this population, which research shows are at a higher risk, and help to target interventions accordingly.

In Hamilton, this would mean a call to all obstetricians, midwives, and family physicians to acknowledge the disadvantages or challenges their patients face, and to advocate for change at all levels to decrease this disparity. To work with their colleagues, public health, acute care centres, and community organizations to address the challenges facing their patient population, and with the patients themselves, to acknowledge that access to care and support should look the same for all pregnant and postpartum women.

References

Institute of Medicine. (2010). Promoting cardiovascular health in the developing world: A critical challenge to achieve global health. http://www.iom.edu/Reports/2010/Promoting-Cardiovascular-Health-in-the-Developing-World-A-Critical-Challenge-to-Achieve-Global-Health.aspx

Rowe, R. E., Garcia, J., Macfarlane, A. J., & Davidson, L. L. (2002). Improving communication between health professionals and women in maternity care: A structured review. Health Expect, 5(1), 63–83. https://doi.org/10.1046/j.1369-6513.2002.00159.x

American College of Obstetricians and Gynecologists (ACOG). (2019). Levels of maternal care. https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2019/08/levels-of-maternal-care

Provincial Council for Maternal and Child Health (PCMCH). (2022). Maternal and newborn level of care guidance document. https://www.pcmch.on.ca/wp-content/uploads/2022/04/2013-Mat-Neo-Level-of-Care-Guidance-Document-with-Notev2.pdf

Wilk, P., et al. (2021). Multimorbidity in large Canadian urban centres: A multilevel analysis of pooled 2015–2018 cross-sectional cycles of the Canadian Community Health Survey. Journal of Multimorbidity and Comorbidity, https://doi.org/10.1177/26335565211058037

Karches, K., DeCamp, M., George, M., Prochaska, M., Saunders, M., Thorsteinsdottir, B., & Dzeng, E. (2021). Spheres of influence and strategic advocacy for equity in medicine. Journal of General Internal Medicine, 36(11), 3537–3540. https://doi.org/10.1007/s11606-021-06723-1

Hamilton Public Health Services. (2024). Hamilton’s Community Health Status Report. City of Hamilton. https://www.hamilton.ca/people-programs/public-health/public-health-services-annual-report