Health policymakers and practitioners often use words like “downstream” or “upstream” to describe the vastly different points at which people may receive care.

Downstream means late in the process, well after the onset of a problem, and often long after a problem has become entrenched. For example, a child who is treated for an anxiety disorder — even if that treatment is successful — is getting help downstream.

But give the child a prevention program, before they have a disorder, and you’ve moved “upstream.” And in doing this, a few things can happen. You can immediately improve the quality of the child’s life — by reducing their distress and removing impediments to their healthy development. You can also alter the trajectory of a young child’s life, by reducing the negative impact of adversity. In turn, this can contribute to a lifetime of well-being and resilience. Upstream interventions can also save healthcare costs, for example, by reducing emergency room visits.

Better yet, you can help the mother as well as the child — before the child is even born. Then you’re moving upstream in way that’s likely to make the most profound difference.

That’s the motivation for Lenora Marcellus, pictured above, an Associate Professor in the School of Nursing at the University of Victoria. A member of the BC Healthy Connections Project scientific team, her original background is in neonatal intensive care. “A lot of the work I’ve done is downstream, when women haven’t been supported when they’ve needed it most, early on,” she says. She notes that much of her work in these hospital settings was with families who were struggling with disadvantages such as not having enough to live on, or not being able to get prevention programs themselves when they needed them.

Marcellus has also volunteered for almost 20 years with a young mothers’ group in her community and has seen first-hand the many challenges faced by young parents. Her experience providing downstream intensive healthcare services is what motivates her to embrace the goals of the BC Healthy Connections Project, which involves an evaluation of the Nurse-Family Partnership (NFP) program.

With NFP, public health nurses visit young women who are in early pregnancy and preparing to parent for the first time — providing them with home visits and intensive supports until the child’s second birthday. The program starts earlier than any other early childhood program, making it a decidedly upstream approach.

For the BC Healthy Connections’ evaluation, NFP is being compared with BC’s existing prenatal and early childhood services. The goal is to learn whether BC can replicate positive results from other countries. These results have shown that NFP can improve prenatal health, parenting, and children’s mental health and development, while also lifting young mothers out of poverty.

According to Marcellus, BC Health Authorities already try to help new moms with highly complex challenges, so they can help their children. But these families need extra supports and it’s often hard for them to get them. That’s why she’s so committed to the BC Health Connections Project.

“With NFP, the public health nurse brings a really unique set of skills,” Marcellus says of the program. “They’re developing a relationship and connecting with the new moms. What’s more, the meeting takes place in the mom’s own home or wherever feels safe for her. That’s very different from a professional setting.”

Although the teen pregnancy rate has declined in BC, young moms continue to be a vulnerable population because these very young women also have other challenges, Marcellus says. They can be invisible, stigmatized or judged. Just as bad, they often fall between the cracks when it comes to getting help. “We know that in society today it’s pretty hard to be an independent adult in our very expensive province,” Marcellus says.

“We could call it a pay now or pay later opportunity,” she says, adding that she would much rather see society pay now. “Investing in programs like NFP is likely to pay huge dividends over generations — for families and communities at large.”
The Nurse-Family Partnership is available only through the BC Healthy Connections Project for the duration of study recruitment. Practitioners or young pregnant women can click here for more information.

Harriet MacMillan sees the BC Healthy Connections Project (BCHCP) through a unique set of lenses.

One involves her role as the Chedoke Health Chair in Child Psychiatry at the Offord Centre for Child Studies at McMaster University. There, she co-led a Hamilton-based project piloting Nurse Family Partnership several years ago. Looking through that lens, she is eager to see Canadian young mothers-to-be get more help — via Nurse-Family Partnership (NFP). Basically, this program sees public health nurses frequently visiting young, pregnant women — in their own homes — from early in pregnancy until their children turn two years old.

Another lens comes from MacMillan’s position as BCHCP nominated co-principal investigator — along with Charlotte Waddell from Simon Fraser University. Here, MacMillan primarily wants to ensure the rigorous demands of a randomized controlled trial of NFP are met.

“I think it’s such an important study and it’s wonderful we have the opportunity to conduct this trial in BC,” she says. “The collaboration between the scientific team and the BC policy makers is terrific.”

In helping launch the Hamilton pilot project several years ago, MacMillan worked with a team adapting the American NFP materials to meet Canadian needs and standards. For example, in the US, each nurse is responsible for 25 young mothers-to-be. “In Canada, partly due to issues like geographic distance, we determined it should be no more than 20,” she says. As well, even though both countries support breast-feeding, “Canada tends to put a bigger emphasis on it.”

The pilot project also examined the whole referral process. MacMillan recalls: “We asked, are we able to get referrals and are we able to recruit women?” And once women did join the project, the team asked: “Do both the women and the nurses find NFP acceptable?” Indeed, the pilot project showed that NFP referrals were feasible, and that women and nurses both welcomed NFP.

“I think it’s fair to say that these young mothers were a high-risk group, but basically what we found was that once they were on board and engaged, they really seemed to appreciate the program.”

As for whether the program will succeed in Canada the answer remains to be seen. “My hope is that we will see similar benefits associated with NFP here as compared with the US trials,” MacMillan says.

“NFP is such a unique program where nurses develop this special relationship with mothers prenatally, such that mothers become very tuned in to the needs of their child, and so we hope it will improve outcomes for both mothers and their children.”

Note that Nurse-Family Partnership is available only through the BC Healthy Connections Project for the duration of study recruitment. Practitioners or young pregnant women can click here for more information.

As a midwife in the Okanagan Valley, Suzanne Lobb sees pregnant women who fit every description – from younger to older, from poor to wealthy, and from many different cultural backgrounds. But regardless of their background, each woman receives the same initial message. “We give everyone a card and encourage them to call public health,” Lobb says. “Once they’re out of our care — six weeks after they deliver — it’s easier for them to stay connected to services in the community if they have a stronger connection to public health.”

In the Okanagan Valley, Lobb works with a number of women who are either “young, transient or single parents.” The key issue she identifies is solo-parenting, sometimes because the women’s partners need to leave the community to find sustainable jobs. “There’s also a large number of very young, very transient women who are single parents,” she says, referring to women who often have to move from place to place because they have no home of their own. “And a lot of dads are in and out of the picture,” she adds. Apart from everything else, this often means that the women don’t have the emotional support they need.

That’s one of the reasons why Lobb is a big believer in the BC Healthy Connections Project. “I support the study because I think it’s important to know whether Nurse-Family Partnership is effective,” she says. In her own practice she’s noticed that young women who sometimes have to miss midwifery appointments can often still attend support groups offered by other community-based organizations. “That kind of support is really valuable to those young women,” she says, adding that one-on-one assistance provided by a nurse might be even more effective.

As a mother of three, herself Lobb delivers almost 50 babies each year. She wants to see all of them grow into healthy, happy adults. “I really want to see the study succeed,” she says.

Note that Nurse-Family Partnership is available only through the BC Healthy Connections Project for the duration of study recruitment. Practitioners or young pregnant women can click here for more information.

As a scientific interviewer, Elsa Langdon* now regularly meets with people she wouldn’t otherwise have the privilege of knowing.

Her role, as part of the BC Healthy Connections Project (BCHCP) — a scientific study evaluating the Nurse-Family Partnership program — puts her face to face with young women who’ve dealt with a variety of life experiences. Some have not always had all the supports they needed. Some are living on low income. Some have struggled with finishing school, or with health problems. And now they’re pregnant for the first time.

An intensive child and maternal health program, Nurse-Family Partnership (NFP) gives young women who are preparing to parent for the first time one-on-one home visits with public health nurses throughout their pregnancy. These visits continue until children reach their second birthday. The BCHCP is the first Canadian scientific evaluation of this program.

Says Langdon: “It’s been amazing to me to see how strong these women are. Despite all the challenges they face, they still have so much hope for the future. That’s had a big impact on me.”

Langdon’s job is to speak with all participants in the study (only 50% receive Nurse-Family Partnership; the remainder receive existing health and social services) and track their experiences about being new mothers over two-and-half years.

What has struck Langdon the most is how much she has in common with these women. “A realization that’s been slowly washing over me is this sense of how similar we all are,” she says. “If you read about their lives on a piece of paper you may think, ‘They’re so different from me. We have nothing in common.’ But when I sit down and talk [to them], I realize they have the same worries, the same concerns that I do.”

She has also been surprised by the enthusiasm of the participants. “At the beginning I didn’t expect that,” she says. “We were taking up a lot of time and asking a lot of questions. I thought we’d be more of a burden.” Instead, the women taking part often express their gratitude, saying that being in the study gives them a voice. One young woman, in particular, said it made her “feel she was part of something that was bigger,” Langdon says. “It was great to know she saw it as a positive thing.”

Note that Nurse-Family Partnership is available only through the BC Healthy Connections Project for the duration of recruitment. Practitioners or young pregnant women can click here for details on how to reach public health and determine eligibility for the BCHCP.