A fundamental re-think of preconception health, education and care is required, according to a visiting expert from Scotland, Dr Jonathan Sher.
In a presentation to the 14th National Rural Health Conference in Cairns last week, Sher highlighted initiatives in the United States and Scotland aimed at improving outcomes for new and future generations.
But his main message was that everyone – as individuals, professionals and organisations – must embed a focus on preconception into their lives and work.
This is the latest story from the conference by journalist Melissa Sweet, who is covering it for the Croakey Conference News Service. You can bookmark the stories here and watch her interview with Sher at the bottom of the post, as well as a full broadcast of the plenary session.
Please also visit the link here for Twitter coverage of the conference by Dr Tim Kelly, tweeting for @WePublicHealth.
Melissa Sweet writes:
“What’s the difference between Las Vegas and early childhood?”
The answer, according to Dr Jonathan Sher, is that “what happens in Vegas stays in Vegas, but what happens in early childhood never stays in early childhood.”
Sher, a preconception consultant in Scotland, asked the question at the start of his presentation to the recent National Rural Health Conference in Cairns to make a point about the need to transform thinking around preconception care.
“It’s not a question they’ve ever been asked before,” he later told Croakey. “It’s a way of reminding people … that those early experiences, that sometimes which we don’t even consciously recall, are the ones that shape us for the rest of our lives, and sometimes unfortunately mis-shape us.”
Sher, who has worked in the United States, Australia and in Scotland in early childhood education and rural health, called for transformation in thinking about preconception care, instead of focusing on just the period just before pregnancy.
“We need to radically redefine the meaning of ‘early’ when we think about early childhood or early intervention,” he said.
“The beginning of parent education is how we are ourselves parented. That creates the template; that creates the default setting in our brains about what parenting is like.
“If it’s good, we tend to emulate it; if it was bad, we will become fiercely determined to not repeat the harsh experiences we’ve had.
“Preconception health education and care should be envisaged as taking place across the life course, starting with our own birth, continuing in childhood and adolescence; it’s not just about a few months before becoming pregnant.”
Primary prevention
Such a focus had potential to shift the policy focus on “closing gaps” that now dominate in Australia, the United States and the United Kingdom in education attainment, health status, income and wellbeing.
But in addition to closing the gap, the focus should also be on stopping those gaps from ever opening in the first place through primary prevention, he said.
“My message to you is, preconception is where primary prevention truly starts. It’s also the time where it succeeds most easily most cheaply and most successfully.
“We know it’s never too late to do something good for another person, but if we wait to help only once a child goes to preschool or has reached school age, then there are some important boats that have already sailed.
“Preconception truly begins at our beginning, rather than solely in the months just before pregnancy; this has profound implications for policy, practice and our own understanding. If the gap never opens, you don’t have to spend your time energy and money closing it.”
Sher said that the roots of much inequality and social injustice began well before pregnancy.
“Remember that pregnancy and birth outcomes and the life trajectories that follow can be predicted with some accuracy, maybe depressing accuracy in some cases, at the outset of any pregnancy,” he said.
“Women who are relatively healthy, reasonably educated, unstressed and supported at the time of conception are more likely, but not guaranteed, to have safe pregnancies and to deliver healthy babies.
“By contrast, women who are unhealthy, who have substance abuse problems, who are deprived in various ways and who are living stressful, chaotic lives when they conceive are notably more likely, but not doomed, to have much riskier pregnancies and to deliver more vulnerable babies.”
Making rural and remote Australians and their communities more wealthy, more empowered and fairer, as well as less marginalised and less deprived would significantly improve pregnancy and overall birth outcomes, he said.
Inadequate or missing preconception health, education and care is both a cause and a consequence of poverty, discrimination, racism, substance abuse, poor physical and mental health and the other problems bedevilling too much of rural and remote Australia, he said.
The lack of attention to preconception care was exemplified in the common description of women “falling” pregnant, he said.
“It reflects a passivity and a ce sera attitudes that underlies preconception. No one falls into a profession or buying a home; we plan for these significant life events and yet we fall into pregnancy and parenthood, arguably the most significant life events that most people will ever experience.”
Programs in action
Sher outlined programs in Scotland and the United States that are developing a new focus on preconception care.
To be effective, it was crucial that such programs created a sense of agency and empowerment relating to health decisions, especially about fundamental questions around parenting.
Mellow programs
A Scottish initiative, the Mellow Parenting program was designed to help vulnerable young mothers better relate to their children. Recognising the need for earlier intervention, Mellow programs were then developed to target toddlers, babies and then “bumps and dads-to-be”.
Now, Sher said, the Mellow approach is being piloted with young people leaving care who are dramatically more likely to become early parents and to have children who end up in care. The program is designed to break this cycle.
Earlier intervention for depression
Recognising that most women who develop post natal depression have had undiagnosed and untreated depression antenatally, the Church of Scotland is developing programs for women with depression, addiction or obesity who are pregnant, and for before they become pregnant.
Early childhood
Sher suggests that parenting programs are occurring in preschool when young children are being encouraged – but not commanded – to wash their hands, brush their teeth, eat more healthy foods and get plenty of outdoor exercise, developing healthy habits that can last a life time.
“Most importantly, doing this with preschool children in the right way, in an empowering way is the foundation of a sense of agency, the understanding that their knowledge and decisions really matter in staying healthy,” Sher said.
“This is a crucial precursor to making more complex choices about their own wellbeing as they get older, including about pregnancy, parenthood and relationships; this work of developing agency and sense of optimism.”
One Key Question
Sher also described “a brilliant” program developed in Oregon and since rolled out in 22 US states, based on the “deceptively simple idea” of GPs regularly asking all women of child bearing age, no matter why they are coming to the doctor, about whether they want to become pregnant in the next year.
Those who say no are offered contraception, and the others are offered preconception health, education and care.
The One Key Question program was developed to provide preconception health, education and care, knowing that about 50 per cent of pregnancies – and more in rural, remote and marginalised communities – are unplanned.
While no randomised controlled trials have been conducted, the program has been rolled out to 22 states, and evaluations have been “very encouraging”.
“This was created by women, for women for the most part – and women appreciate being asked, for the most part,” he said.
“How it is done and the quality of the follow up is what makes or breaks its effectiveness.”
All hands on deck
However, Sher said his main message was that Australia should not look to adapt overseas programs or establish Ministries or Departments of preconception health.
“I have very intentionally chosen examples that are not reliant on new legislation or millions of new dollars or years of revamped education or training,” he said.
“What I am looking for is an ‘all hands on deck’ effort,” he said. “It’s not a spectator sport.
“The magic is to see what you are already doing; to see what you are already good at in light of how they can be applied to preconception health, education and care across the life course.
“This is about people working in their own backyards and their own organisations and professions and with the others around them to each do what they can.
“The crucial slogan is that nobody can do everything, but everybody can do something to make sure that the next generation of mothers and fathers are better prepared, better supported.”
“We can and must do better with and for the next generation.”
See further by Dr Jonathan Sher:
Dr Sher is currently Director of Sher Consultancy. Previous positions include Scotland Director of WAVE Trust; Director of Research, Policy and Programmes, Children in Scotland; CEO of the North Carolina Child Advocacy Institute; Lead Consultant, Annenberg Rural Challenge; Co-founder of Rural Entrepreneurship through Action Learning; CEO of the Rural Education and Development Inc.
Croakey readers may also be interested to explore the work of First 1000 Days Australia, being led by Professor Kerry Arabena.
Watch this interview with Dr Johnathan Sher
You can also watch the full plenary session in which he presented, published online by the National Rural Health Alliance (Dr Sher is introduced at the 35:00 mark)
What delegates said on Twitter
And a bit of explanation needed for these – sparked as Dr Sher stripped to his Friend of the National Rural Health Alliance shirt during presentation. He is a long-time member.
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