ARCHIVED - Summative Evaluation of the Canada Prenatal Nutrition Program 2004-2009

Key Findings

3.0 CPNP Relevance

The question of relevance addresses whether there is a continuing need for CPNP. This means determining whether the program addresses an actual need, whether the program is necessary for the need to be fulfilled, and whether the program continues to be consistent with Agency, government-wide and other priorities. Outlined below are the specific RMAF questions on relevance assessed against the evaluation evidence and applicable indicators.

3.1 Threats to Maternal and Infant Health in Canada

Through every stage in life, health is determined by complex interactions between social and economic factors, the physical environment and individual behaviour. This is no less true for infants during the perinatal period. Some threats are cyclical, in that they affect certain segments of the population at different times, while others are more consistently present. This section reports on the extent to which threats to the health of pregnant women, their infants and families persist, such as: poverty (including unemployment and food insecurity); teen pregnancy; access to health services and basic amenities; and personal health practices. 

A major source of the data informing this section was a comprehensive literature review that synthesized a wide range of data from a variety of sources including, but not limited to:

• Statistics Canada’s health and labour data
• The Maternity Experiences Survey
• The Canadian Perinatal Health Report
• The Canadian Institute of Child Health (CICH)

As well, a wide range of both published and “grey” literature was included to support the findings described here.

Poverty and Unemployment

Low monthly household income poses a direct threat to personal health and also influences other risk factors that moderate health (World Health Organization (WHO), 2008). Low income limits access to basic amenities (e.g. food, shelter, clothing, etc), education, health care services, and social support networks (WHO, 2008). Living in poverty is associated with low birth weight outcomes for infants (Muhajarine, 2009). In turn, low birth weight increases the risk of perinatal illness and is associated with a higher rate of long-term health problems, including disabilities such as cerebral palsy and learning difficulties (CICH, 2000). Despite the fact that the rate of poverty in Canada has decreased from 12.5% in 2000 to 10.5% in 2006, the rates continue to be higher for certain vulnerable populations. For example, a greater proportion of lone-parents, immigrants, and off-reserve Aboriginal persons tend to live in poverty than do members of the general Canadian population. In 2006, the poverty rates for single parents and immigrants were 26% and 19% respectively. Data from the 2006 Aboriginal Children’s Survey indicates that 49% of First Nations children under the age of six and living off-reserve were from low income families. As well, trends in poverty statistics tend to be closely related to the rate of unemployment which, since 2008, has risen in Canada. As a result, poverty persists as a threat to the health of vulnerable Canadians and programs like CPNP, that address the health needs of these vulnerable populations, are still relevant. Between 2002 and 2006, over three quarters of CPNP participants had a household income of $1,900 or less per month.

Food Insecurity

Living in a household with a monthly income below the low-income cut-off (LICO)Footnote 6 is also associated with food insecurity and irregular consumption of nutritious foods (PHAC, 2008c). In Canada, nearly 50% of households in the lowest income levels report food insecurity. Similarly, 41% of CPNP participants reported living with food insecurity. Low-income neighbourhoods tend to have a limited number of grocery stores and poor access to nutritious food that is affordably priced. These neighbourhoods also have a greater concentration of fast food services than high-income neighbourhoods (PHAC, 2008c)). Studies have confirmed that as household income drops the consumption of energy-dense but nutrient-poor food increases (Drewnoswski, 2009). Proper nutrition is especially important for pregnant women as the maternal diet can either promote, or hinder, the healthy growth and development of the fetus. Interestingly, although those living in poverty are at the greatest risk for food insecurity, this population is also recognized to have a decreased likelihood of initiating breastfeeding despite the fact that breastfeeding is considered the most important guarantee of food security for infants according to Canada’s Action Plan for Food Security (McGuire, 2009; Government of Canada, 1998).

Teen Pregnancy

In its most recent Canadian Perinatal Health Report, PHAC highlights that teenage pregnancy is an important public health concern as both teen mothers and their infants face a higher risk for adverse health outcomes. For example, teenage mothers are at greater risk of experiencing poor maternal weight gain and anemia, while their infants are at greater risk of being born prematurely, with a low birth weight or with a congenital abnormality (PHAC, 2008b). The Maternity Experiences Survey reports that teen mothers are also less likely to initiate breastfeeding and to take folic acid supplements (PHAC, 2009b). Although there has been a decline in teen pregnancy nationally, certain populations continue to experience higher rates, such as off-reserve Aboriginal women (24% compared to 10% among Canadians). Between 2002 and 2006, approximately 12% of pregnant women entering CPNP were under the age of 19.

Access to Health Services

In general, the proportion of the household population aged 15 and over who are facing difficulties accessing routine or ongoing health care is increasing in Canada. In 2007, 16.7% of Canadians 15 years or older reported these difficulties; a figure that rose from 15.8% in 2003. Delays in accessing health care during pregnancy can lead to adverse health outcomes for both mother and baby (McGuire, 2009). Having fewer than four prenatal visits has been associated with preterm birth (defined as birth at < 37 weeks gestation) and low birth weight (LBW) (defined as < 2500g) outcomes (Tough, 2001). In particular, maternal health care and social and community services are less available and less accessible to pregnant women and new mothers living in rural and remote areas (McGuire, 2009). In addition, Canada is experiencing a shortage of maternity care providers. This shortage is especially prevalent and problematic in rural and remote areas where there are also a greater proportion of women travelling long distances to give birth to their infants. One area where CPNP targets support is to rural communities and communities in the north of Canada where access to services is difficult.

Personal Health Practices

There is a wealth of evidence to support prenatal interventions for pregnant women aimed at preventing or attenuating unfavourable outcomes for both the women and their infants by improving maternal health practices (McGuire, 2009). In particular, pregnant women who are facing challenging life circumstances are often in greatest need of early and consistent intervention. Prenatal interventions such as CPNP have been shown to mitigate risk by improving personal health practices within vulnerable populations.

Smoking

Certain health practices, such as smoking and drinking alcohol during pregnancy, are associated with significant risks to the health of the infant. Smoking during pregnancy is associated with intrauterine growth restriction, increased risk of preterm birth, spontaneous abortion, placental complications, stillbirth, and sudden infant death syndrome. In general, smoking behaviour is declining in Canada; however, rates continue to be higher among certain socio-demographic groups. According to a report from the Chief Public Health Officer of Canada in 2008, 19% of the Canadian population aged 15 and older smoked (PHAC, 2008c). The highest smoking rates occur among Canadians with low incomes, Aboriginal populations, those living in Canada’s North, and those who have some secondary education, but who have not completed college or university. These same populations are targeted by CPNP. Participant data collected through the Welcome Card in 2005-2006 revealed that 30% of pregnant women smoked upon entering CPNP.

Alcohol Consumption

Mothers who consume alcohol during pregnancy put their babies at risk for serious health and development problems arising from Fetal Alcohol Spectrum Disorder (FASD) and Alcohol-Related Birth Defects (ARBD). Infants affected by FASD or ARBD may experience cognitive, behavioural, neurodevelopmental, physiological, or physical impairments over the course of their lives. Between 2000 and 2005 the rate of maternal alcohol consumption during pregnancy in Canada has decreased from 12% to 10%, but remains high among some populations, such as Aboriginal women (McGuire, 2009). ICQ2 findings from 2002-2006 revealed that 41% of CPNP participants had used alcohol during their pregnancy, over half of whom had consumed more than five drinks in one day. As with smoking, CPNP targets populations at greatest risk for consumption of alcohol during pregnancy.

Breastfeeding

Breastfeeding has been associated with benefits such as lower rates of gastrointestinal and respiratory diseases, fewer allergies, improved vision, and cognitive development. Rates of breastfeeding initiation in Canada increased between 2000 and 2005. However, mothers living below the LICO, teen mothers, mothers with low educational levels and Aboriginal women were all less likely to initiate breastfeeding than other women. CPNP targets women who are less likely to breastfeed and achieves an average initiation rate of over 80%.

Summary

Threats to the health of pregnant women and their infants, such as poverty, teen pregnancy, poor access to health care, smoking and alcohol consumption, are declining for the majority of Canadians. However, disparities in health persist among certain vulnerable populations who often experience these threats at higher rates than do most Canadians. As such, the ongoing relevance of CPNP, which endeavours to mitigate these risks and improve infant outcomes, is apparent.

3.2 Objectives and Priorities

CPNP was developed as a result of a federal government priority to promote and protect the health and well-being of children. This section will evaluate the extent to which the program objectives remain consistent with domestic as well as international commitments.

Domestic Commitments Related to CPNP

CPNP was developed in response to the commitment made by the Government of Canada at the 1990 United Nations World Summit for Children to invest in the well-being of vulnerable children. In 1992, the Government of Canada launched Brighter Futures: Canada’s Action Plan for Children^{Footnote 7}, which put in place a number of initiatives aimed at promoting the health and well-being of children. In 1994, CPNP was created to extend activities in this area to the prenatal period.

In 1997, the federal, provincial, and territorial governments committed to develop a National Children’s Agenda (Social Union, 1997). The focus was on a long-term comprehensive strategy that would improve the well-being of children and address their developmental needs. It was recognized that all levels of government would need to be involved and that additional sectors in each jurisdiction would also need to be engaged including: health, social services, justice, and education. CPNP was one of the programs that laid the foundation for intergovernmental collaboration on the health and well-being of children.

As well, in 2000, the federal, provincial, and territorial governments (with the exception of Quebec) came together under the Early Childhood Development (ECD) Agreement (Social Union, 2000) with a commitment to foster the well-being of children across Canada. Through the Agreement, the Government of Canada agreed to provide funding for the improvement and expansion of early childhood development programs and services related to (i) healthy pregnancy, birth, and infancy; (ii) parenting and family supports; (iii) early childhood development, learning, and care; and (iv) community supports. CPNP was identified as one of the key initiatives that would support the Government of Canada’s action on early childhood development as decided in the ECD agreement.

In addition to these issue-driven commitments, PHAC also outlines its own commitments every year in the Report on Plans and Priorities (RPP) (PHAC, 2008a). One of the six priorities PHAC outlined in the 2008-2009 RPP is to “lead several government-wide efforts to advance action on the determinants of health.” The determinants of health include income and social status, social support networks, education and literacy, employment and working conditions, social environments, physical environments, personal health practices and coping skills, healthy child development, biology and genetic endowment, health services, gender, and culture. The support offered by CPNP addresses several of the aforementioned determinants of health that contribute to improving the health of children and pregnant women facing conditions of risk.

International Commitments Related to CPNP

In 1991, Canada ratified the United Nations Convention on the Rights of the Child (UNCRC) to become bound by the provisions of the Convention (United Nations, 1989). CPNP is aligned with the principles of Article 18 of the UNCRC, which affirms the role of parents as the primary caregivers who should be provided with the supports necessary to care for their children. CPNP provides pregnant women and new mothers who are facing conditions of risk with the opportunity to access community supports, including food supplementation; nutrition counselling, support, and education; and referral and counselling on health and lifestyle issues. These supports provide women with the tools and resources needed to care for themselves and their infants. As well, CPNP is aligned with the principles of Article 24, which affirms the right of every child to access health care services and enjoy the highest attainable standard of health. CPNP acts on these principles to protect and promote the health of children by reducing the incidence of unhealthy birth weights, improving the health of mothers and infants facing conditions of risk, and encouraging breastfeeding.

In 1998, the Government of Canada released Canada’s Action Plan for Food Security in response to the World Food Summit (WFS) held in Rome, Italy two years earlier (Government of Canada, 1989). The 187 countries that attended the WFS, including Canada, committed to reduce by half the number of under-nourished individuals by 2015. As part of its nutrition plan, the government highlighted the importance of promoting and protecting breastfeeding and supporting the right of women to breastfeed and the rights of infants to be breastfed. In the Canada’s Action Plan for Food Security the government states that “breastfeeding is the most important guarantee of food security” for a majority of infants (Government of Canada, 1989). CPNP supports and promotes breastfeeding and has adopted the WHO recommendation that infants be exclusively breastfed for their first six months of life.

In May 2002, the Government of Canada participated in the United Nations General Assembly Special Session on Children which unanimously adopted a declaration and plan of action entitled A World Fit for Children. In response, the Government of Canada developed A Canada Fit for Children^{Footnote 8} (Government of Canada, 2004). To achieve the goals outlined in Canada’s declaration, the Government of Canada indicated that it would undertake a multi-disciplinary approach to address the underlying social factors affecting the health and well-being of children, including: employment, income, education, and the status of women, in addition to the immediate health care needs of children. CPNP is showcased in A Canada Fit for Children (Government of Canada, 2004) as an area of investment aimed at fulfilling these commitments given the program’s mandate to: provide resources and support to pregnant women who face conditions of risk (including poverty, lack of employment, and low levels of formal education), and to modify unfavourable personal health practices assumed by women during pregnancy that increase the health risks faced by their children during infancy and later in life.

Summary

The objectives and priorities of CPNP align with those of PHAC; however, the broader scope of the program considers other federal and international goals as well. Domestically, CPNP is most directly aligned with priorities that address the health and well-being of children in Canada. Internationally, CPNP is aligned with commitments made by the Government of Canada, especially those concerned with mitigating health disparities and inequities and taking action to promote the health of individuals beginning in the early years.

3.3 Program Value to Stakeholders

Health supports and services are made available to Canadians in many ways. To be considered effective, these services must be of value to stakeholders. This section reports on the degree to which the federal government is perceived to play a supportive role in ensuring the health of pregnant women, their infants and families.

The literature supports the federal role in addressing health disparities affecting pregnant women and their infants and families and calls for a national approach. The report of the WHO Commission on Social Development of Health – “Closing the gap in a generation – Health equity through action on the social determinants of health” – is a prime example. It calls for national governments to take action on improving the health of citizens by addressing health disparities and inequities that persist among them. The 2009-2010 PHAC Program Activity Architecture (PAA) identifies priorities related to children that reflect this action. These priorities are: to continue supporting targeted and evidence-based health promotion strategies for vulnerable children and families, and to promote children’s rights and well-being in Canada and internationally. Both of these priorities relate to the work and mandate of CPNP.

Increasing Access to Services

The proportion of the household population aged 15 and over facing difficulties accessing routine or ongoing health care is increasing (McGuire, 2009). As a result, the ability of CPNP to increase access to services for those facing challenging circumstances and, when appropriate, refer participants to other services within the community is of significant value. CPNP provides support specifically to at-risk populations and, through referrals, acts as an access point to other community services that cannot always be offered through CPNP projects themselves. These partnerships also enhance awareness of health issues affecting at-risk populations within the community. This kind of collaboration between organizations is noteworthy and ensures that awareness of available services is built between both participants and the agencies that serve them. The importance of these kinds of intangible benefits, such as providing referrals and developing participants’ knowledge and skills, is often underestimated; however, these fundamental activities are integral to the goals of CPNP and are linked to all three of the program’s intermediate outcomes.

Table 2 illustrates how CPNP projects integrate with other community organizations to increase participant access to health services and to improve the ability of community organizations to reach women who are most at-risk. In a typical year, CPNP projects identified more than 1,600 different referrals and these are illustrated in the table below.

(PRA Inc., 2007b)

In addition to cooperation between CPNP projects and other community organizations, new community programs, activities and/or services often spin-off from CPNP projects. ”Spin-offs’ create additional access points to health services within the community. In 2005-2006, 50% of projects reported a “spin-off” that resulted from their project. Examples of these new community programs include: awareness activities for FASD; projects and programs for fathers, teens or young parents; fitness or recreation; prenatal classes; and other programs, activities and services.

Ultimately, CPNP provides access to services that enhance, but do not duplicate, other services within the community. Illustrative of this fact is that, among the 187 projects that completed the IPQ data collection tool in the 2005-2006 fiscal year, 98% of projects agreed that their CPNP project offered at least one unique service within their community. The chart below illustrates some of the unique supports offered by CPNP projects in the community they served.

(PRA Inc., 2007b)

Increasing Community Capacity

Two ancillary objectives of CPNP are to build capacity and increase intersectoral collaboration. The program acts on these objectives by increasing community capacity to provide health services to at-risk populations through partnerships with community organizations. Given that these at-risk populations can often be hard to reach, CPNP provides a venue through which partners can directly provide services to participants, or from which participants can be referred to other services in the community.

Although partnerships between community organizations and CPNP projects are diverse, some of the most common partners include:

• health professionals
• not-for-profit and community organizations (libraries, drop-in centres, food banks)
• schools (universities and community colleges)
• other government programs
• business.

In 2005-2006 nearly all CPNP projects (98%) had at least one partner and most projects had several partners. An exploration of these partnerships and the value of community collaborations is provided in greater detail as a principle of a Population Health Approach.

CPNP also leverages additional funding to provide services to pregnant women, their infants and families within CPNP projects and elsewhere in the community. For example, in 2005-2006, over $8 million in additional funding was leveraged by CPNP projects. This amount was over and above the established funding available from federal, provincial/territorial, municipal and other sources. This funding is often used for other related initiatives, such as the Fetal Alcohol Spectrum Effects (FASE) Strategic Initiative led by the Government of Alberta or for pilot projects that use CPNP sites as their base.

In addition to creating job opportunities for community members, CPNP projects also provide opportunities for participants to contribute to the programs and services offered by their projects by way of both paid and volunteer positions. In 2005-2006, 74% of projects reported that participants also volunteered within their project; 41% reported that participants were hired as staff members. This skill-building capacity within the community illustrates how the projects provide tangible benefits to the communities they serve. Moreover, allowing former participants to share their knowledge and experiences with new participants enhances the ability of CPNP projects to effectively serve at-risk populations.

Summary

It is clear that CPNP remains valuable to its stakeholders as it provides a variety of benefits to both communities and individuals. CPNP enhances access to services directly - through the projects themselves, as well as indirectly through referrals to other community services. “Spin-off” projects inspired by CPNP further increase community capacity to deliver a variety of services to pregnant women, their infants and families. As well, partnerships within the community enable service providers to have direct access to hard-to-reach populations. This also helps to build community capacity and strengthen community linkages. Finally, offering opportunities to former program participants for paid work and volunteering extends capacity building to the individual level.

4.0 CPNP Impact

In order to reduce disparities in health, at-risk populations need to be reached. This section reports on whether at-risk pregnant women are adequately represented within the CPNP population and examines the ways in which the program has improved their health practices and the birth outcomes of their infants. As well, this section assesses whether the project services are being delivered through a population health approach, as originally designed.

4.1 Risk Profile of CPNP Participants

The primary objective of CPNP is to reach women facing challenging life circumstances given that their infants are at increased risk of experiencing unfavourable outcomes such as poor perinatal health or low birth weight. In this way, the program addresses its ultimate goal – to improve health and reduce health disparities of pregnant women and their infants. CPNP considers the following circumstances to be conditions of risk:

• poverty
• teenage pregnancy
• social or geographic isolation with poor access to services
• recent arrival to Canada
• substance use (alcohol or drugs)
• family violence
• Aboriginal status

Studies have shown a strong link between social disadvantage and preterm births, low birth weight, and small-for-gestational-age (Kramer, 1987; Wilkins, 1991; Berkowitz, 1993; Luo, 2004; Luo, 2006; Martens, 2002). In particular, lower levels of maternal education and smoking during pregnancy have been associated with unfavourable birth outcomes (Millar, 1998), as has poverty, which is associated with malnutrition, unhealthy living environments, increased risk of illness and stress (McMurchy, 2008). Many of these risk factors co-exist among the populations served by CPNP. This section will outline the various socio-demographic characteristics of CPNP participants and provides a description of their pregnancy-related health practices. Finally, this section will present a comparison of the risk factors existing among CPNP participants compared to the general Canadian population.

Socio-demographic Characteristics of Participants

A four year profile of CPNP participants, constructed to support the quantitative impact analysis performed in 2009, revealed the following information regarding select risk characteristics: over 80% of CPNP participants had a monthly household income of $1,900 or less, with nearly 10% reporting no income at all; almost 12% were teenagers; close to one quarter were Aboriginal; and nearly 28% were recent immigrants (having lived in Canada less than 10 years) (Muhajarine, 2009). The geographic location of participants was not assessed, but other studies have confirmed that many CPNP projects serve rural, remote and/or isolated areas where there is reduced access to health services (PRA Inc., 2007b). Data regarding the presence of family violence were not collected in the quantitative study, though it is not uncommon for CPNP participants to present with this risk characteristic (Muhajarine, 2009).

(Muhajarine, 2009)

Health Practices of Participants

The quantitative analysis also revealed that, between 2002 and 2006, many women entering CPNP projects reported unhealthy behaviours during pregnancy (Muhajarine, 2009). CPNP services are meant to address these behaviours. Table 5 outlines the percentage of women entering the program with behaviours that put their health and the health of the unborn child at risk. More than 40% of participants indicated that they had consumed alcohol since becoming pregnant, over half of whom reported having had at least five drinks in one day. Information on participant use of illicit drugs while pregnant was not collected, but through narrative data, it is known that some women entering the program use drugs while pregnant (Estable, 2008).

(Muhajarine, 2009)

Pregnancy Related Health Issues of Participants

Whether due to socio-demographic characteristics, personal health practices or other reasons, women entering CPNP often present with pregnancy-related health risks. The percentage of women entering CPNP with select health risks are shown below.

(Muhajarine, 2009)

There is a wealth of evidence to support prenatal interventions for pregnant women to prevent adverse outcomes, especially for those at greater risk of poor birth outcomes. Pregnant women who were single, separated or divorced, less than 25 years old, had less than high school education, and/or smoked had greater odds of becoming unreachable at some point during their pregnancy (Tough, 2007). Prenatal interventions such as CPNP can reduce the likelihood of these negative circumstances for these vulnerable populations.

Risk Profile Comparison – CPNP Participants and the General Population

The findings above illustrate that CPNP does indeed reach vulnerable pregnant women who may be putting their health and the health of their infants at-risk. In order to evaluate how successful CPNP has been in reaching at-risk women in Canada, participant risk characteristics can be compared to the overall population of new mothers in Canada. The proportion of at-risk individuals among CPNP participants far exceeds the proportion of at-risk individuals present within the general population (PRA Inc., 2007a). To illustrate these proportions a sample of the general population of new mothers from the 2005 Canadian Community Health Survey (CCHS) compared to the 2005-2006 CPNP population with respect to select risk characteristics. The results showed that:

• 73% of CPNP population compared to 8% of CCHS respondents reported a monthly household income below $1600
• 26% of CPNP population compared to 5% of CCHS respondents reported that they were under 20 years of age,
• 30% of CPNP population compared to 8% of CCHS respondents reported that they were single
• 23% of CPNP population compared to 4% of CCHS respondents self-identified as Aboriginal
• 40% of the CPNP population compared to 12% of the CCHS respondents reported drinking alcohol during their pregnancy
• 40% of the CPNP population compared to 24% of the CCHS respondents also reported smoking during their pregnancy

Figure 2 – Risk Factor Comparison between CPNP Participants and the General Canadian Population (2005-2006)

(CPNP-ICQ2 and Cycle 3.1 CCHS 2005)

Summary

CPNP is designed to provide health supports and services to address health inequalities among pregnant women and their infants in Canada. In order to be successful at reducing health inequalities, CPNP endeavours to provide these services to those most at-risk. The studies described above have shown that CPNP effectively reaches populations with socio-demographic and health behaviour characteristics that put them at risk (PRA Inc., 2007a).

4.2 Improvements in Maternal and Infant Health following Exposure to CPNP

Of primary importance to CPNP is achievement of the ultimate outcome which is to contribute to improved health and reduced health disparities for pregnant women and their infants who are facing conditions of risk. The following section investigates the extent to which this outcome has been achieved.

The impact of CPNP on the health practices of pregnant women and the birth outcomes of their infants was analysed using data collected through the IPQ and ICQ2 tools. The findings were also compared to health outcome data for the general population derived from the CCHS and with current literature on similar intervention programs. Another dataset, consisting of over 500 “stories” submitted by CPNP participants and project staff between 2003 and 2006 through the IPQ tool, formed the basis of the qualitative assessment of the program.

Impacts were measured using the following indicators:

• Improvements in maternal health behaviours – pregnancy weight gain; vitamin or mineral supplement use; smoking and alcohol cessation; and breastfeeding initiation and duration.
• Improvements in birth outcomes – preterm births; LBW; small-for-gestational-age (SGA) and large-for-gestational-age (LGA) babies; and poor neonatal health.
• Comparative analysis – select health behaviours and birth outcomes of CPNP participants assessed against the general population.

These indicators align with two key intermediate and long-term outcome indicators of the CPNP RMAF. These RMAF outcomes include:

• Improved personal health practices of CPNP participants
  
  
• Improved health and social outcomes for CPNP participants and their infants

Program and Participant Outcomes Reported by CPNP Projects

A national qualitative assessment of participant and programmatic outcomes was a central component of the analysis of impact for CPNP (Estable, 2008). CPNP participant and project staff perspectives were gathered as part of multi-year qualitative assessment of CPNP. The three outcomes most commonly reported by participants and project staff were that CPNP: reduced isolation, increased the initiation and duration of breastfeeding and improved overall maternal health. These three outcomes as well as other frequently reported outcomes are illustrated in Figure 3.

Figure 3 – CPNP: Most Frequently Reported Program Outcomes (2003-2006)

(Estable, 2008)

The qualitative assessment highlighted reduced social isolation, a crucial indicator of supporting and improving maternal mental health, as the most frequently reported CPNP outcome (42%) (Estable, 2008). The qualitative analysis identified that reducing social isolation was a key program outcome especially for those “hard to reach clients” such as those who were geographically isolated or newcomers to Canada. Social support was found to increase emotional well-being and reduce symptoms of depression among participants. Other reported benefits of social support included the role of CPNP staff in the assessment of women for signs of depression and referrals of those women to appropriate health professionals.

Low income mothers of young children experience particularly high levels of depression, often in combination with other risk factors. In the general population the rate of maternal depression is approximately 12%, whereas among at-risk mothers the rates are in the 40-60% range (Isaacs, 2004). Particularly for low-income children, maternal depression can be a barrier to success in their early school years. Addressing maternal depression through a parenting and very early childhood lens, as is done by CPNP, can help parents but also will pay off for children in the short and longer term (Knitzer, 2008).

The identification of mental health/social support provided by CPNP projects to participants is relevant given that the broader literature suggests that social support may have a mediating influence on the relationship between life stress and the development of pregnancy complications (Norbeck, 1983). Reviews have shown benefit from both ‘professional’ and ‘peer’ support. Peer support from a woman in one’s community, who has a similar socio-economic background and is experiencing similar life stresses, may be qualitatively different from support from a healthcare professional, who has broad professional knowledge and experience. The professional may not share the same socio-economic background or life concerns, and who often provides other professional services as well as support (Hodnett, 2003). A quantitative exploration of the other most frequently reported outcomes illustrated in Figure 3, including breastfeeding initiation and duration, improved maternal health, and improved infant health, is found below.

Impact of CPNP on Participant Health Behaviours

Quantitative data was collected through the ICQ2 regarding participants’ health practices and birth outcomes. In 2009, the University of Saskatchewan’s Population Health and Evaluation Research Unit (SPHERU) analysed four years of this data (2002-2006) to determine the impact of different levels of program exposure on health practices and birth outcomes. In scanning exposure patterns, it was found that:

• Almost half of participants entered the program by the 20th week of their pregnancy (or partway through their second trimester) while 30% of participants did not enter the program until after the 29th week of their pregnancy.
• The number of participant contacts with CPNP varied widely; over half had 11 or fewer contacts but over 20% made contact with the program 12 to 257 times.
• About half of participants attended CPNP for more than 20 weeks, based on a typical entrance at 4 months of pregnancy until 4 months after their baby was born. There is the potential for approximately 52 weeks of attendance.

The impact of CPNP on participants’ health practices and infant birth outcomes was analysed across three categories: levels of program exposure (high compared to low), type of services received and socio-demographic characteristics.

“High exposure,” a relative measure, was defined as entering the program earlier during their pregnancy, having a greater number of program contacts, and staying longer in the program than other participants.

The relationship between maternal health practices and infant outcomes was not compared to individual level of risk (based on the presence of multiple risk factors); however, socio-demographic, pregnancy-related and behavioural risk indices were created to account for multiple risk factors. These indices were then controlled for, as appropriate throughout the various analyses. An area for future investigation would be to assess relationships between participant risk and program exposure; for example, whether higher risk mothers received more contacts with the program. A high level of program exposure was defined as entering the program early in pregnancy, having several contacts with the program, and/or staying in the program for as much of the prenatal period as possible. This analysis was conducted to determine whether these three categories were associated with a greater likelihood of a positive change in personal health behaviours during pregnancy. The health behaviours assessed were: pregnancy weight gain, vitamin or mineral supplementation, smoking cessation, smoking reduction, alcohol use, breastfeeding initiation and breastfeeding duration. Outlined in Table 7 is summary of potential health outcomes that can be avoided as a result of effective prenatal interventions as identified in the literature and in-line with outcomes identified in the evaluation of CPNP. This is not to say that these interventions will prevent these outcomes in all cases, only to present results that have been found in the literature and in certain cases.

(McMurchy, 2008)

Pregnancy Weight Gain

Overall, greater program exposure was related to healthier outcomes during pregnancy, except with respect to weight gain during pregnancy. Analysis revealed that 45% of women with a pre-pregnancy BMI in the “normal” range gained an average of 5.63kg more than the recommended amount for their BMI category (Muhajarine, 2009). The point at which women entered the program, the number of contacts they had, and how long they stayed in the program did not make a significant difference in their weight gain outcomes. In contrast, the services they received from CPNP did affect their pregnancy weight gain. For example, women who received group nutrition counselling had a reduced risk of gaining too much or too little weight compared to those who did not receive this service, while women who received a dietary assessment and lifestyle education or counselling had an increased risk of gaining too much weight. Differences in weight gain were found across socio-demographic groups within the category of participants with the highest exposure to CPNP. Specifically, women at greatest risk of gaining more than the recommended amount of weight during pregnancy were under 19 years of age. Interestingly, the only group of women who were more likely to gain too little weight during pregnancy were those with incomes of greater than $1,900 per month.

Vitamin or Mineral Supplement Use

Supplement use was assessed across the categories of “never” to “irregular” consumption, “never” to “daily” consumption and “irregular” to “daily” consumption. Higher exposure to CPNP was associated with a greater likelihood of increasing supplement use among participants who never took them or took them irregularly prior to entering the program. Specifically, CPNP exposure, whether beginning earlier in pregnancy, at higher intensity or for longer duration, was consistently related to increased use of supplements during pregnancy in each category of change. Moreover, CPNP participants who had overall high exposure to CPNP services were more than twice as likely than those with lower overall exposure to increase their use of supplementation. With regard to specific CPNP services, receiving one-on-one nutrition education or counselling or ‘other’ services was associated with the greatest likelihood of increasing use of supplements.

There is a strong positive relationship between CPNP program exposure and vitamin and/or mineral supplement use. The literature indicates that some types of supplementation during pregnancy have been associated with improvement in preterm and low birth weight outcomes; although in some cases there is insufficient evidence to draw definitive conclusions (McMurchy, 2008). Supplementation with folic acid is well known to reduce the incidence of congenital malformation such as neural tube defects (Wilson, 2007). Vitamin and mineral supplementation has also been linked to reduced incidence of certain types of paediatric cancers (Goh, 2007).

Smoking and Alcohol Cessation

The cessation of smoking by CPNP participants could not be attributed to the receipt of a particular service; however, with regard to program exposure, those smokers who initiated contact with CPNP earlier in their pregnancy, or who had more contact with the program were 25% and 18% more likely to quit respectively (Muhajarine., 2009). Analysis of socio-demographic characteristics and smoking behaviour showed that the group for which exposure to CPNP had the greatest impact on likelihood for smoking cessation was Aboriginal pregnant women who were almost 50% more likely to quit (Muhajarine, 2009). Higher program exposure was associated with a 19% increased likelihood of smoking reduction and an impact was also noted among immigrant women who were found to be four times more likely than other women to reduce the number of cigarettes they smoked (Muhajarine, 2009).

With regard to alcohol consumption during pregnancy, it was found that a high exposure to CPNP was associated with a 40% increased chance of quitting (Muhajarine, 2009). An analysis of alcohol cessation and CPNP support received showed that women who received group nutritional counselling were the most likely to quit drinking alcohol (Muhajarine, 2009). Similarly, analysis across socio-demographic groups revealed that immigrant women were the most likely to quit drinking; however, there were no large variations among socio-demographic groups. Inexplicably, two services – one-on-one nutrition and lifestyle counselling – were related to a decreased likelihood of quitting (Muhajarine, 2009). Overall, the majority of CPNP clients (84%) reported that they quit drinking during pregnancy.

The results above illustrate that CPNP program exposure was positively linked with smoking cessation and alcohol reduction. Smoking during pregnancy is associated with an increased risk of preterm birth and infant mortality while alcohol use during pregnancy has been consistently linked to FASD and cognitive delays (Stade, 2009). CPNP provides support to reduce these risk behaviours and, as a result, improves the likelihood of healthy mothers and infants. A recent Canadian study found that the adjusted annual cost associated with FASD was $21,642 per child aged zero to 21 years (Stade, 2009). Given that Muhajarine and colleagues (2009) were able to illustrate that mothers who participate in CPNP projects often quit or reduce their alcohol consumption, we may infer that CPNP helps to avoid the development of FASD thereby preventing the significant financial burden associated with this life-long disorder. Future analyses may wish to generate a more precise estimate of the number of FASD cases avoided to determine the true contribution of CPNP to cost-savings in this respect.

Breastfeeding Initiation and Duration

The quantitative analysis by Muhajarine and colleagues (2009) revealed that, overall, 81% of CPNP participants initiated breastfeeding between 2002-2006. Among those who received breastfeeding support and education this rate increases to 84% (McMurchy, 2008). Both breastfeeding initiation and duration were highly impacted by program exposure. Women with the highest intensity of attendance (greatest number of visits to the program) were found to have a 35% greater likelihood of initiating breastfeeding than women with fewer contacts with the program. With respect to socio-demographic characteristics, participants who were most likely to initiate breastfeeding were: single or divorced women (22%), Aboriginal women (27%), women who had not completed high-school (21%), women 19 years of age or younger (28% and women who reported food insecurity (24%). Inexplicably, certain services (receiving food supplements and dietary assessment) were associated with a lower likelihood of breastfeeding initiation for some women. Despite this, participants who received breastfeeding education and support were 59% more likely to have ever breastfed than those who did not receive support (McMurchy, 2008).

Strong positive associations were found with respect to duration of breastfeeding and CPNP exposure. Women who had overall high exposure to the program were more than four times (or more than 400%) more likely to breastfeed longer than women with lower exposure to CPNP. Among individual exposure variables, women who had frequent contact with the program were 4.6 times more likely to breastfeed longer than women with fewer contacts. Dramatically, women who stayed in the program longer were a remarkable 21 times more likely to breastfeed longer than women who attended CPNP for a shorter length of time. Among socio-demographic groups, single women and newcomers to Canada were 7.5 and eight times more likely to breastfeed longer than other women. However, unexpectedly, women reporting “no income” were found to have an increased likelihood to breastfeed for a shorter duration with more program exposure.

(Muhajarine, 2009)

Impact of CPNP on Birth Outcomes

One of the most frequently reported program outcomes in the qualitative analysis by Estable et al. (2008) was the increased incidence of healthy birth weights (Figure 3). The impact of CPNP on birth outcomes among singleton infants born to CPNP participants was further analysed in the quantitative study by Muhajarine et al. (2009). Five birth outcomes were examined in relation to program exposure, type of services received and socio-demographic characteristics. Specifically, these outcomes were: preterm birth, LBW, SGA, LGA, and various neonatal health complications.

Preterm Births

Infants of women with the highest exposure to CPNP were 26% less likely to be born preterm than those with low exposure. In relation to services obtained, receiving food supplements and group nutrition counselling were associated with the lowest likelihood of giving birth preterm (40% less likely and 27% less likely respectively). In contrast, receiving the service of lifestyle counselling was associated with a 19% increased risk of preterm birth. There were also varying results across socio-demographic groups with some groups experiencing decreased likelihood of preterm births and other groups experiencing no significant impact. Overall, no significant pattern could be determined.

Low Birth Weights

Participants who had the highest exposure to CPNP were 34% less likely to have a LBW infant compared to those participants with lower program exposure. With regard to services received, group nutrition counselling was most strongly related to reduced risk of LBW outcomes (24%). In contrast, lifestyle education or counselling was associated with an 11% increased likelihood of having a LBW infant. With the exception of those reporting no income, the positive effect of overall high CPNP exposure on reducing the risk of LBW was seen equally across socio-demographic groups. This impact was slightly greater among women who had completed high school and women over the age of 34 years.

Small-for-gestational-age and Large-for-gestational-age

Participants with overall high program exposure were 11% less likely to have a SGA baby, a slightly weaker association than was demonstrated between program exposure and preterm birth and birth weight. Although receipt of food supplements resulted in a reduced likelihood of preterm birth, receiving food supplements was associated with a 33% increased likelihood of having a SGA baby. With respect to socio-demographic characteristics, the likelihood of having a SGA baby varied among women with high exposure to CPNP.

Contrary to other birth outcomes, greater program exposure was associated with a 22% increased likelihood of having a LGA baby despite controlling for presence of maternal gestational diabetes, a condition known to result in LGA babies. Interestingly, women who gave birth to LGA babies were not consistently found to be the same women who had gained more than the recommended amount of weight during pregnancy, as is often the case for mothers of LGA babies. An exploration of the rationale for this unexpected outcome should be considered in a future CPNP evaluation. Results varied with respect to services received. For example, participants who received food supplements were 39% less likely to have a LGA baby while those who received dietary assessment were 36% more likely to have a LGA baby. Finally, likelihood of having a LGA baby varied across socio-demographic categories. The mothers in the “high exposure” group with the greatest likelihood of experiencing a LGA outcome for their infant were: newcomers to Canada (33%), women over the age of 34 years (34%), women who had not completed high-school (36%), women with moderate food security (32%) and Aboriginal women (27%).

Birth complications - Poor Neonatal Health

The neonatal health issues specifically tracked through the ICQ2 were: respiratory problems, infections, cerebral palsy, heart problem or conditions, Down syndrome, broken collarbone, jaundice and spina bifida. Participants also had the ability to report other issues they or their infant experienced at birth. Results showed that participants who had high exposure to CPNP programming were 17% less likely to report their newborn experienced health issues related to poor neonatal health. This was particularly true for participants who received food supplements or group nutrition counselling; however, other nutrition and lifestyle counselling services were associated with a higher likelihood of poor neonatal health.

(Muhajarine, 2009)

In general, greater exposure to CPNP is associated with increased likelihood of adoption of healthy behaviours during pregnancy and in the post-partum period. As well, greater exposure to CPNP is associated with increased likelihood of positive birth outcomes for the infants of participants, which is likely a result of the improvements their mothers have made to their health practices and lifestyle. The next section investigates how the health practices and birth outcomes of CPNP participants compared to those of the general Canadian Population.

Summary

The quantitative analysis revealed that, in general, the more exposure women have to CPNP, the more likely they are to improve their personal health practices during pregnancy and in the post-partum period. Similarly, high exposure to the program increases the likelihood of a favourable birth outcome for their infant (Muhajarine, 2009). Specifically:

• Participants who had higher program exposure were more likely to increase their use of vitamin or mineral supplements; reduce smoking; cease alcohol consumption; initiate breastfeeding and to breastfeed their infants longer than participants with lower exposure
• Participants who had had higher program exposure were less likely to have infants born: preterm, of low birth weight, that were small-for-gestational-age or that were of poor neonatal health than participants with lower exposure.

Certainly, we must acknowledge that CPNP is one of many factors influencing maternal health practices and infant outcomes. Additional mitigating factors such as receipt of other community health and social services must be recognized, as must be the personal circumstances affecting each participant that may facilitate or hinder their efforts.

4.3 Breastfeeding and Birth Weight – A Comparative Analysis between CPNP Participants and the General Population

Despite the evidence that CPNP is having a positive effect on the health of its at-risk participants, one might anticipate that disparities in health practices and birth outcomes would persist among the CPNP population compared to the general population. To assess this, a comparison between CPNP participants and the general population was completed by Prairie Research Associates in 2007. This comparison data was also used in a study by McMurchy and Palmer (2008) regarding two major CPNP outcomes, namely: rates of LBW outcomes and breastfeeding initiation. A description of the results is presented below.

Breastfeeding: CPNP Participants Compared to the General Population

An analysis comparing CPNP participants to CCHS respondents revealed that, in 2004-2005 the rates of breastfeeding initiation were equivalent (87% and 86% respectively) (PRA Inc., 2007a). Figure 4 presents a comparison of breastfeeding rates, stratified by socio-demographic characteristics, reported by CPNP participants who received breastfeeding support, CPNP participants who did not receive this support and CCHS respondents. In most cases, despite experiencing conditions of risk, higher rates of breastfeeding initiation were found among CPNP participants who received breastfeeding education and support compared to Canadian mothers with similar socio-demographic characteristics (McMurchy, 2008).

Figure 4 – Breastfeeding: CPNP Participants compared to the General Canadian Population (2005-2006)

Click on the image to view a larger format

(McMurchy, 2008; PHAC - CPNP-ICQ2; Statistics Canada - CCHS 2005)

Predictors of breastfeeding initiation are relatively similar between CPNP participants and the general population. Results indicated that pregnant women who had food insecurity and who were not born in Canada were more likely to breastfeed. Those who were single or smoked during their pregnancy were less likely to breastfeed (PRA Inc., 2007b; McMurchy, 2008).

Almost all CPNP projects evaluated in the IPQ provide some type of breastfeeding preparation and support (PRA Inc., 2007b). Analysis revealed that greater program exposure was strongly linked with increased breastfeeding duration. There is a considerable body of evidence demonstrating the benefits of breastfeeding for infants and their mothers. Research also shows that the longer the duration of breastfeeding and amount of exclusive breastfeeding yield even greater benefits (Horta, 2007). Early advantages of breastfeeding include reduced mortality among preterm infants, and fewer allergies. The evidence also points to reduced rates of Type One and Type Two diabetes (Horta, 2007), obesity (Fewtrell, 2004, Gillman, 2001), raised blood pressure (Horta, 2007), and childhood cancer later in life (Davis, 1988). Breastfeeding has also been shown to be associated with visual and neural development, speech and cognitive development, and performance on intelligence tests and in school (Horta, 2007).

Studies in Canada have shown that improving women’s knowledge about breastfeeding and its benefits during pregnancy can increase the rate and duration of breastfeeding (Dennis, 2002; Mossman, 2008). Women who breastfeed longer are more likely to lose excess weight (Dewey, 1993) and exhibit less postpartum anxiety than women who bottle fed their infants (Virden, 1988). As well, literature shows that breastfeeding can play a role in enhancing family relationships (Cohen, 2002; Falceto, 2004; Jordan, 1993; Li, 2004; Sullivan, 2004).

Low Birth Weight Outcomes: CPNP Infants compared to the General Population

Despite the significant risk characteristics that are known to increase the likelihood of LBW outcomes among women facing challenging life circumstances, a comparative analysis revealed that the incidence of LBW among CPNP participants was similar to that of the overall Canadian population (6.4% and 6.0% respectively) (McMurchy, 2008). CPNP cannot be directly credited for this smaller-than-expected disparity in LBW outcomes between CPNP participants and the general population; however, given that participants who had the highest exposure to CPNP were 34% less likely to have a LBW infant compared to those participants with lower program exposure (Muhajarine, 2009), the strong contribution of CPNP to maternal and infant health is evident.

The impact of specific CPNP services on health behaviours and birth outcomes was variable; however, CPNP participants who received nutritional interventions (especially vitamin and mineral supplementation) and prenatal counselling were found to have lower rates of LBW than those CPNP participants who did not receive these services (Muhajarine, 2008). LBW is associated with significant risks of neonatal morbidity and mortality as well as significant health care costs (McMurchy, 2008). Studies have also documented a relationship between birth weight and longer-term outcomes such as cognitive development, educational attainment, labour market outcomes, and adult health (Strauss, 2000; Matte, 2001; Jefferis, 2002; Durousseau, 2003; Morley, 2004; and Behrman, 2004).

Figure 5 compares the rates of LBW outcomes among CPNP participants and the general Canadian population. As illustrated, the distribution of birth weights is relatively similar between CPNP and all Canadian births. In fact, CPNP participants had fewer infants delivered in the lowest birth weight category. Given the myriad risk factors putting CPNP participants at increased risk for LBW outcomes, it is significant that CPNP participants experience equivalent rates of LBW outcomes as the Canadian population.

Figure 5 – Low Birth Weight: CPNP Infants compared to the General Canadian Population (2005-2006)

(PHAC - ICQ2, Statistics Canada. CANSIM Table 102-4509-2005)

The analysis by McMurchy and Palmer (2008) demonstrated that nutritional and prenatal counselling in combination with food, vitamin or mineral supplementation appears to have had an impact on low birth weights. With a view to better design, target and expand programs offered by CPNP evidence suggests that a clear understanding of the diets and nutritional deficiencies that affect vulnerable women could help to improve the efficiency of food support programs and the impact of nutritional education and food supplementation on maternal and child health outcomes (D’Souza, 2006).

Summary

Despite the additional hardships faced by CPNP participants, the rates of LBW and breastfeeding among CPNP participants were nearly equivalent to those of the general Canadian population. Whether results are compared within the CPNP population (among those with higher or lower exposure to the program, or based on receipt of various services) or to the Canadian population at large, it is apparent that CPNP is effective at reducing the rates of LBW outcomes and increasing the rates of breastfeeding initiation among its target population. The comparative analysis indicated that rates of LBW and breastfeeding in CPNP are generally as good as, if not better than, those of Canadian births.

4.4 Implementation of a Population Health Approach

Population health strategies are designed to maintain and improve health status of whole populations, and to reduce inequities in health status between population groups. A range of individual and collective factors determine health. These determinants interact with each other to create complex patterns of health status within a population. Key principles of the population health approach, as defined by Health Canada’s Population Health Template include:

• focusing on the health of populations
• addressing the determinants of health
• employing evidence-based decision making
• increasing upstream investments in health
• applying multiple strategies
• collaborating across multiple sectors
• employing mechanisms for public involvement
• demonstrating accountability for health outcomes

This section provides an assessment of national performance measurement data for CPNP, including national IPQ data and the national qualitative analysis of CPNP success stories that describe how CPNP operates within a population health approach.

CPNP Application of a Population Health Approach

The underlying design and delivery of CPNP programming adheres to the principles of the population health approach. Key indicators used to assess the methods by which projects apply a population health lens as identified in CPNP’s RMAF include:

• addressing the health of populations and the multiple determinants of health (specifically healthy child development; personal health practices; social support networks and individual capacity and coping skills).
• collaboration and partnerships
• mechanisms for participant involvement
• evidence-based decision making

Addressing the Determinants of Health through Multiple Strategies:

The qualitative analysis conducted regarding for CPNP illustrates the extent to which projects address the broader determinants of health (DOH) (Estable, 2008). As a comprehensive program, CPNP implements a population health approach through multiple strategies. These strategies include food and vitamin supplementations, nutritional counseling, food preparation training, breastfeeding education and support, education and support on infant care and child development, and referrals and counseling on health and lifestyle issues.

Over three quarters of projects address issues related to participant income by providing food supplements, voucher, coupons and transportation. Also, over half of projects address social support networks, a social environment, personal health practices and coping skills through group and one-on-one nutritional counseling, group and one-on-one lifestyle counseling, and child care services. Health services are offered through nutritional counseling, vitamin and mineral supplements, dietary assessments, and referrals to health professionals. Projects also offer culturally-specific programming. Table 10 outlines the most frequently offered services.

(PRA Inc., 2007b)

The qualitative analysis by Estable and colleagues (2008) illustrated the extent to which CPNP projects specifically tailor multiple activities and services to be responsive to the broader DOH including: healthy child development; personal health practices; social support networks and individual capacity and coping skills. Described in Table 11 are examples of how participants and project staff have interpreted CPNP’s response to the DOH. These examples were extracted from the “stories” submitted by the projects via the IPQ tool.

(Estable, 2008)

Collaboration and Partnerships

CPNP collaboration is best illustrated through the extensive multi-sectoral partnerships created at the community-level. Participants that attend CPNP are at-risk populations and are often hard to reach through traditional health service delivery systems. CPNP provides a venue through which community partners can provide services directly to at-risk populations or from which participants can be referred to other community organizations. The type and frequency of CPNP partnerships are detailed in Table 12.

(PRA Inc, 2007b)

Other collaborating partners for CPNP include Friendship Centres and other Aboriginal organizations, drop-in centres, service clubs, parks and recreation/community centres, as well as community health centres, public health and regional health authorities. These partners often provide human resources such as nurses, dietitians and social workers. These partnerships allow CPNP to build intersectoral collaboration to promote and support maternal and infant health. Partnerships also provide an opportunity for CPNP to leverage additional support. For example, in 2005-2006 almost 50% of total staff hours were in-kind contributions through partnering organizations (PRA Inc., 2007b).

The findings from the qualitative analysis substantiate the value and frequency of partnerships that were quantified by the national performance measurement analysis (PRA Inc., 2007b). The qualitative analysis identified positive collaboration such as the involvement of sectors, other than health, becoming involved in the provision of services in a significant way (i.e. social services organisations, housing, food banks, shelters) and the movement towards multi-sectoral decision-making (Estable, 2008). In fact, improvements in partnerships and collaboration were the fifth most frequently reported outcome in the national qualitative analysis of CPNP.

Mechanisms for Participant Involvement

CPNP projects successfully employ a variety of mechanisms for participant involvement. Participant volunteerism is an on-going component of CPNP delivery and occurs at all levels and positions. Overall, IPQ analysis illustrated that in a typical year, 74% of CPNP projects reported more than 65,000 hours of volunteerism. In addition, 41% of projects indicated that former participants had been hired as employees working directly for the program. Table 13 provides a breakdown of the types of volunteerism and paid staff positions in which participants were involved. An exploration of the value of volunteerism is addressed in the costing section of this report.

*Note: Respondents could provide more than one answer; totals may sum to more than 100%.(PRA Inc., 2007b)

Evidence-Based Decision Making

One important principle of a Population Health Approach is the application of evidence-based decision-making. Indicators of evidence-based decision-making can include the application of best practices in program design, delivery and continuous improvement. In order to accurately assess this principle, a key informant study on best practices was conducted and findings were grouped as follows:

1. CPNP mechanisms for collecting and applying best practices
2. Program improvements identified based on evidence of effective practices.

An assessment of this principle also assesses the program RMAF question- “To what extent does CPNP apply evidence of effectiveness to inform continuous improvement?”

1. Mechanisms for Collecting and Applying Best Practices

CPNP has several mechanisms for collecting and applying best practice information to facilitate program improvements. Mechanisms exist locally within projects, regionally and nationally. These include:

• adherence to CPNP financial and site monitoring
• evaluation -based national project renewal
• regional advisory committees and networks
• provincial / territorial Joint Management Committees

In addition, the performance of CPNP has been monitored on an ongoing basis through various data collection tools. Recently, an Integrated National Evaluation Tool (INET) was developed based on feedback regarding previous evaluation tools. The objective of the INET is to improve national data collection and ensure alignment with a public health framework. As well, the Welcome Card was revised to improve collection of socio-demographic data to permit evaluation of the reach of CPNP in addition to other potential measures. These tools will form the basis for future evaluations of the program.

One mechanism that is specifically mandated to bring together program staff for the sharing of best practices on priority issues facing projects and participants is the CAPC/CPNP National Projects Fund (NPF). This fund also develops resources that can be shared nationally for the benefit of the program as a whole. The mandate of the NPF is to:

• support and strengthen CAPC/CPNP projects through resource development and information sharing and dissemination and training on specific issues
• encourage and stimulate the development of a national network of community-based children’s programs
• share the knowledge base among CAPC and CPNP projects and with communities

NPF resources have been developed and disseminated on issues such as family violence, father involvement and reducing teenage pregnancy. Following a training session on NPF CPNP resources, an independent evaluation found that awareness of toolkits and available resources increased for more than 75% of project representatives who participated in the training (Howell, 2009). As well, more than 85% intended to share the information and resources they received, and over 87% intended to use the information and resources (Howell, 2009).

2. Program Improvements

Evidence of improvements to CPNP following implementation of effective practices has been found in several areas including program management and evaluation, program supports and services, and program resources. Examples of these include:

• successful management practices developed from feedback on best practices from CPNP projects in the regions were rolled up in 2005 and distributed to program consultants by way of a CPNP Orientation Manual, a Guide for Applicants, and a database of Standard Operating Procedures.
• evaluation results have been used by projects in several regions to improve awareness of CPNP programs and promote the program to stakeholders and to leverage additional funding for the program.

Both the quality and quantity of CPNP services have improved through the application of effective practices. In Alberta, projects were able to partner with the FASE Strategic Partner Fund to deliver specialized FASD services and to leverage FASD-specific funds. In Ontario, there are partnerships with organizations that specialize in teen-specific issues for teen participants in CPNP. In the Atlantic Region, projects are partnering with the Breastfeeding Committee of Canada to establish a Baby Friendly Initiative site. In the Manitoba/Saskatchewan Region, two project sites were able to integrate a successful postpartum adjustment program into CPNP postnatal programming as a result of training obtained through a partner. In the Northern Region, projects have been able to address the challenges unique to the North by partnering with Health Canada’s CPNP which provides support to pregnant women and new mothers living on reserves. The adoption of several successful pilot projects has also improved CPNP services across the country. For example, the tobacco reduction program STARSS (Start Thinking About Reducing Secondhand Smoke) developed by Action on Women’s Addictions Research and Education (AWARE) in 2006-2007 has helped women reduce or cease smoking while pregnant.

Summary

It is evident that CPNP projects are applying multiple strategies to address the broader DOH. Activities and services within CPNP do not operate in isolation. Projects frequently identify and apply multiple strategies and activities including home visiting, group sessions, counselling, food preparation and even transportation. These programs represent embedded community networks that are responsive to and part of the broader systems change. Key findings indicated that:

• CPNP designs and delivers programs to be responsive to the DOH
• CPNP projects are successfully partnering at multiple levels
• CPNP projects offer ample opportunity for participant involvement at all levels of decision-making.
• CPNP projects apply evidence-based decision making through the identification and application of best practices.

5.0 Cost-Efficiency and Cost-Effectiveness

The final question of this summative evaluation focuses on the degree to which CPNP operates efficiently and effectively. The information is presented in two section, the first being program cost efficiency while the second explores the cost effectiveness of CPNP’s impact on two key birth outcomes, specifically: the incidence of low birth weight and initiation and duration of breastfeeding.

Costing information of the kind presented in this section is extremely difficult to obtain for programs that are implemented in a community-based setting in diverse ways across the country. That this data could be collected speaks to the strength of the national data collection system in place for the program.

The robust data available regarding CPNP, primarily from the IPQ, ICQ2 and Welcome Card, includes information on costs, services provided and participant characteristics. This resulted in a dataset comparable to available national data (such as the CCHS), which is the reason that much of this costing data could be calculated and presented. The collection and analysis of costing data presented in this evaluation are a first for PHAC and are considered a significant achievement by both program staff and program stakeholders.

5.1 Cost Efficiency

The economic evidence supports the existence of interventions designed to improve the life chances of infants and young children. A preliminary economic analysis of early childhood interventions indicated that programs, like CPNP, with objectives such as reducing low birth weights and increasing rates of breastfeeding initiation, appear highly cost-efficient as they release resources and generate benefits that outweigh program costs (Shiell, 2007). Factors associated with economic efficiency include the quality of the programming, the characteristics of the participants, the characteristics of the context in which the interventions were implemented, and possible interactions between each of these factors.

Early child development programs have been shown to be among the most cost-efficient of public health interventions leading to a wide range of beneficial social outcomes. The results of several programs, similar in mandate and philosophy to CPNP, proved to be highly cost-beneficial (Shiell, 2007). This means that the monetary value of the benefits generated by the programs exceeded their costs. Baseline benefit-cost ratios of these equivalent programs ranged from 0.5 to 16.1, meaning that each dollar invested generated ‘economic returns’ ranging in value from $0.50 to $16.10 (Shiell, 2007). The potential for application and comparability of this evidence to policy and practice in Canada needs to be examined further.

The economic case for early childhood intervention rests on the argument that investing in the early years of a child’s development yields benefits in the future worth more than the costs. Improvements in a child’s cognitive, behavioural and social performance translates into better educational outcomes, reduced reliance on special education, reduced incidence of juvenile crime, improved employment prospects (both in terms of likelihood of employment and earnings when employed) and better health (McMurchy, 2008)

CPNP receives funding from a variety of federal, provincial and territorial sources. Municipalities and partner organizations also contribute to CPNP program costs. The table below outlines these contributions.

(McMurchy, 2008)

Leveraging of Resources

CPNP has also been effective at leveraging funds. The value of in-kind resources contributed to the projects, such as the time and skills of public health nurses and dietitians, is estimated at $9.4 million annually. This figure is based on the salaries of equivalent positions within CPNP. The substantial contribution of in-kind resources is equal to 54% of the value of program funding received from PHAC and 20% of the overall program funding. Additional contributions are made through in-kind donations. Although the amount of in-kind donations was not assessed, over 80% of projects receive donations such as facility space, project materials, equipment and items for participant use. These donations allow for more diverse use of funding dollars.

Cost per Participant

Based on the total amount of direct funding reported by each CPNP project (n=187), the average cost per CPNP participant from program entry to exit was calculated to be $513.57 in 2005-2006, with a minimum of $19.94 per participant and a maximum of $11,840.65 per participant. When accounting for the value of the in-kind staff time (but not the volunteer time), calculated based on the salaries for the various staff positions paid by CPNP projects, the total value of CPNP resources is $52.9 million. Based on this more inclusive total, the average cost per CPNP participant increases from $513.57 cited above to $623.56, with a minimum of $21 per participant and a maximum of $11,916 per participant. The projects with participant costs far above the average may have incurred start-up and expansion costs, or capital investments in the year that the funding data was collected. The majority of CPNP projects have an average cost per client of $1,000 or less.

Figure 6 – Distribution of the Average Cost per Client by Project^{Footnote 15}

(McMurchy, 2009)

5.2 Cost Effectiveness

Savings Associated with Healthy Birth Weights

Preterm births and LBW result in the use of additional health care resources. In Baffin Island, hospitalization rates were higher among preterm infants (Muggah, 2004). Two cohort studies in the U.K using data from 239,694 births from the Oxford Record Linkage Study assessed hospital utilization and costs attributable to preterm birth. Durations of hospital stays for infants born at < 28 and 28-31 gestational weeks were, respectively, 85 and 16 times longer than for term infants (Petrou, 2003). Other studies also conclude that preterm or LBW infants are significantly more likely to consume hospital and community health services during the early years of life than infants born at full term or at normal birth weights (Brooten, 1986; McCormick, 1991). These studies highlight the potentially avoidable use of hospital resources if there were a reduction in preterm births and LBW.

LBW – generally defined as a birth weight less than 2500 grams – can cause major health problems for an infant and significant health care costs (McMurchy, 2008). LBW can result from premature or preterm birth and can also affect those who are born small for their gestational age, regardless of their pre- or full term status. The underlying causes of preterm birth compared to the causes of LBW may differ. In high-income countries, preterm birth is the major reason for LBW. In low- to middle-income countries (and among the under-privileged in developed countries), maternal malnutrition can lead to underweight babies (Kramer, 1987). For this reason, one of the main objectives of CPNP is to reduce the incidence of LBW, specifically among populations at the greatest risk.

As illustrated in Table 15, interventions targeted towards women at risk of giving birth to LBW infants have been shown to be cost effective. Note that as birth weight data were not readily available for an at-risk population similar to that of CPNP, comparisons were made between CPNP participants (at greater risk of LBW) and all Canadian births. Neonatal hospital costs at birth were applied to each birth weight category and an overall average hospital birth cost was derived for both populations. Dramatic savings can be achieved by preventing birth weights in the lowest birth weight categories.

Despite the hardships faced by the CPNP population, the distribution of birth weights is relatively similar between CPNP and all Canadian births. Moreover, CPNP participants had fewer infants in the lowest birth weight categories. The overall average weighted cost per birth in the Canada was $2,004 compared to a cost of $1,915 among CPNP participants. Thus, the average weighted hospital cost of a CPNP infant was an average of $89.24 less than the neonatal cost for all Canadian births in 2005. This is a remarkable result given that – based on their characteristics of risk – CPNP participants have an increased likelihood of having LBW babies than the overall population of new mothers in Canada. Even more striking cost savings would likely have been obtained if birth weight data had been available for Canadian women with risk characteristics similar to those of the CPNP population but who had not participated in the program (a matched population).

(CPNP – ICQ2 Statistics Canada. CANSIM Table 102-4509-2005)

When CPNP participants were stratified by age, it was found that the greatest cost savings were associated with infants born to mothers under the age of 20, a cohort that represented 26% of the CPNP population assessed in the economic analysis. The cost savings for infants born to CPNP participants aged 20 years or younger compared to infants born to mothers of the same age across Canada were estimated at $233.35. This alone translates into a savings of nearly $1.1 million. This is a critical finding given that serving young pregnant women is part of the mandate of the program and illustrates the fact that CPNP is successfully reaching its targeted audience. Within the age group of mothers 20-34 years of age, the average hospital costs were $91.73 more for CPNP mothers than the general population; however, this result was expected given that the majority of infants born in Canada are to primarily healthy, low-risk women between the ages of 20 and 34 years. In future analyses, it may be useful to construct a comparison population of at-risk women in the general population to investigate whether, measured against an equivalent population, CPNP participants would display hospital cost savings, especially in the 20-34 age group where overall number of births is highest.

Saving Associated with Increasing Breastfeeding

Attempts have been made to quantify the economic benefits of breastfeeding. As an example, the American Academy of Pediatrics estimated a national savings of $2.16 to $3.96 billion if all new mothers breastfed (Calamaro, 2000). Another study by the United States Department of Agriculture Economic Research Service calculated a potential savings of $3.6 billion if breastfeeding rates increased to the level recommended by the Surgeon General (Weimer, 2001).

Looking specifically at the CPNP population within Canada, the rate of breastfeeding initiation is over 80%. In particular, those who received breastfeeding education and support were more likely to breastfeed (84%) than those who did not (75%). The cost savings that result from increasing the initiation and duration of breastfeeding, as is the program’s mandate, come from the costs of diseases avoided in the first year of life, such as gastroenteritis and otitis media and are based on hospital costs and direct physician costs (McMurchy, 2008). In a comparison between infants exclusively breastfed for at least three months and those who were never breastfed, it was estimated that in the first year, for every 1,000 infants not breastfed, there were 2,033 excessive physician visits, 212 extra days in hospital and 609 extra prescriptions related to respiratory infection, gastroenteritis and otitis media (Ball, 1999).

Based on the rates of breastfeeding among CPNP participants, each infant born to a mother who received support would avoid an average of $42 in hospital costs in the first year of life as a result of diseases prevented. Note that this very conservative estimate does not include medication costs, laboratory or diagnostic tests and other direct health care costs. Nor are any indirect costs included such as transportation, lost parental wages, or childcare costs for other children. As a result of this conservative approach, the estimated cost saving do not fully demonstrate the considerable impact of breastfeeding on infant health. These savings increase with the presence of certain risk characteristics, as illustrated in Table 16.

(McMurchy, 2008)

Among CPNP participants, those who did not breastfeed at birth were significantly more likely to report that their infants had respiratory problems (55% more likely) or a heart problem (43% more likely) within the first two weeks of life. As illustrated in Table 17, the rates of respiratory conditions and heart problems in CPNP newborns based on whether or not they were breastfed can have a significant impact on the cost of their health care. Infants who are not breastfed incur greater health care costs for these conditions – ranging between $12 and $40 dollars per infant – than those who are breastfed.

(McMurchy, 2008; PHAC CPNP - ICQ2) * Assumes 50% hospitalization rate.

Although modeling the rates and costs associated with breastfeeding outcomes can provide an estimate of potential cost savings, more precise and detailed cost information could be derived by analysing the health care utilization of a cohort of pregnant women and their infants from birth up to age one or more years.

Summary

Overall, the findings above have established that CPNP is a cost efficient program, specifically in its efforts to increase rates of breastfeeding and decrease rates of LBW. The evidence from the research literature illustrates that CPNP is providing cost savings in relevant areas. With an average cost per client of $1,000 or less, and by leveraging resources worth over 50% of the program’s funding through in-kind resources, the program is operating in a cost-efficient manner. Additionally, when the costing analysis of the program was conducted, cost savings for both main program objectives of reducing the risk and incidence of LBW and increasing the initiation and duration of breastfeeding, were found. Given that the comparison group was the general Canadian population, and not a population experiencing equivalent risk, the results are impressive. Based on the 17,689 CPNP participants included in this analysis, the cost savings provided by CPNP is $1.6 million.