Chapter 1 Maternity Theory
Chapter 1 Maternity Theory
Chapter 1 Maternity Theory
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chapter
Key Terms
atraumatic care
case management
childhood mortality rate
cultural safety
discipline
doula
emancipated minor
ethnicity
ethnocentrism
evidence-based nursing
practice
family
family-centred care
family structure
fetal mortality rate
foster care
infant mortality rate
maternal mortality rate
morbidity
mortality
neonatal mortality rate
registered midwife
religion
social capital
spirituality
Learning Objectives
Upon completion of the chapter, the learner will be able to:
1. Identify the key milestones in the evolution of maternal and child health
nursing.
2. Describe the major components, concepts, and influences associated
with the nursing management of women, children, and families.
3. Compare past definitions of health and illness with current definitions,
as well as the measurements used to assess health and illness in women
and children.
4. Identify the factors that affect maternal, newborn, and child health.
5. Delineate the structures, roles, and functions of the family and how they
affect the health of women and children.
6. Identify how society and culture influence the health of women,
children, and families.
7. Appraise the health care barriers affecting women, children, and
families.
8. Discuss the ethical and legal issues that may arise when caring for
women, children, and families.
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persons ability to lead a fulfilling life and to participate fully in society depends largely on his or her
health status. Although the overall health of children has
improved and the rates of death and illness in some areas
have decreased, the need to focus on the health of women
and children remains. Habits and practices established
during pregnancy and early childhood can have profound effects on a persons health and wellness throughout life. As a society, creating a population that cares
about women, children, and families and promotes solid
health care and lifestyle choices is crucial.
Maternal and newborn nursing encompasses a wide
scope of practice typically associated with childbearing. It
includes care of the woman before pregnancy, care of the
woman and her fetus during pregnancy, and care of the
woman and her newborn after pregnancy, particularly
during the first 6 weeks after birth. The overall goal of
maternal and newborn nursing care is to promote and
maintain optimal health of the woman and her family.
Child health nursing, commonly referred to as pediatric
nursing, involves the care of the child from infancy through
adolescence. There are approximately 7.83 million children under 18 years of age in Canada, accounting for 23%
of the population (Statistics Canada, 2010).
The overall goal of pediatric nursing practice is to
promote and assist the child in maintaining optimal levels of health while recognizing the influence of the family
on the childs well-being. Achieving this goal involves
health promotion and disease and injury prevention as
well as assisting with care during illness. The common
thread in both of these objectives is the care of the family.
Now more than ever, nurses contribute to nearly
every health care experience. Events from birth to death,
and every health care emergency in between, will likely
involve the presence of a nurse. Involvement of a knowledgeable, supportive, comforting nurse often leads to a
positive health care experience. Skilled nursing practice
depends on a solid base of knowledge and clinical expertise delivered in a caring, holistic manner. Nurses, using
their knowledge and passion, help meet the health care
needs of their clients throughout the lifespan, whether the
client is a pregnant woman, a fetus, a partner, a child, or
the parents or family members of a child. Nurses fill a
variety of roles in helping clients to live healthier lives by
providing direct care, emotional support, comfort, information, advice, advocacy, and counselling. Nurses are
often in the trenches advocating for issues, drawing
attention to the importance of health care, dealing with
the lack of resources and timely access to physician care,
and fostering health promotion and illness prevention
rather than focusing primarily on acute care needs.
This chapter presents a general overview of the
health care of women, children, and families and describes
the major factors affecting maternal and child health.
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Historical Development
The health care of children in Canada has changed over
the years due to devastating epidemics, social trends in
this country and abroad, changes in the health care system,
and provincial and federal health care policies that place
increasing emphasis on health promotion and early
intervention (Public Health Agency of Canada [PHAC],
2009a). By reviewing historical events, nurses can gain a
better understanding of the current and future status of
maternal and child health nursing.
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Chapter 1
Figure 1.1 Today, fathers and partners are welcome to take an active role in the pregnancy
and childbirth experience. (A) A couple can participate together in childbirth education
classes. (Photo by Gus Freedman.) (B) Fathers and partners can assist the woman throughout
her labour and delivery. (Photo by Joe Mitchell.)
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Chapter 1
Source: Hodnett, E. D., Gates, S. Hofmeyr, G. J., & Sakata, C. Continuous support for women during
childbirth. Cochrane Database of Systematic Reviews 2007. Issue 3. Art No.: CD003766.
DOI:10.1002/14651858.CD003766.pub2.
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Chapter 1
Family-Centred Care
Family-centred care is the delivery of safe, satisfying,
high-quality health care that focuses on and adapts to the
physical and psychosocial needs of the family. It is a cooperative effort between the family and their caregivers and
recognizes and uses the strengths and integrity of the family. There are three basic principles of family-centred care:
Childbirth is considered a normal, healthy event in
the life of a family.
Childbirth affects the entire family, and relationships
and roles will change.
Families are capable of making decisions about their
own care if given adequate information and professional support (Friedman, Bowden, & Jones, 2003).
The philosophy of family-centred care recognizes the
family as the unit of care. The health and functioning of
the family affect the health of the client and other members of the family. Family members support one another
well beyond the health care providers brief time with
them, such as during the childbearing process or a childs
illness. Birth is viewed as a normal life event rather than a
medical procedure.
With family-centred care, support and respect for the
uniqueness and diversity of families are essential, along
with encouragement and enhancement of the familys
strengths and competencies. It is important to create
opportunities for families to demonstrate their abilities
and skills. Families can acquire new abilities and skills to
maintain a sense of control and empowerment in meeting
their own needs. Family-centred care promotes greater
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family self-determination, decision-making abilities, control, and self-efficacy, thereby enhancing the clients and
familys sense of empowerment. When implementing
family-centred care, nurses seek caregiver input. The
information, suggestions, and advice are incorporated
into the clients plan of care as the nurse counsels and
teaches the family about appropriate health care interventions. Today, as nurses partner with various experts
to provide high-quality and cost-effective care, one expert
partnership that nurses can make is with the clients
family.
Unfortunately, some parents feel imposed on by
nurses expectations of what they are to doa phenomenon that has increased with the recent shortages of nursing
staff. Therefore, it is important that nurses negotiate with
parents to determine the parent role as well as the preferred types and amounts of communication. This is often
the most important factor in the success of interactions
during a childs hospital stay (Shields, Pratt, & Hunter,
2006). There are increasing numbers of pediatric day surgeries and children being discharged earlier with the assistance of community health care services. This places a
heavy responsibility on families who may have little or no
training and often minimal support. There is limited
research on family-centred care in this context and a need
to quantify the real cost, both emotional and financial, for
families who are caring for children with complex health
care needs in the home (Shields et al., 2006).
The impact of family-centred care can be seen in the
models of care delivery for women. Since the 1980s,
childbearing families have been offered increasing options
for care, including hospital redesigns (labour, delivery,
and recovery rooms; labour, delivery, recovery, and postpartum spaces) aimed at keeping families together during
the childbirth experience. This impact also can be seen in
the care of children: rooming-in and liberal visiting policies allow parents and other family members to participate in the childs care (Fig. 1.2).
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Health Status
At one time, health was defined simply as the absence of
disease; health was measured by monitoring the mortality and morbidity of a group. These data remain significant for international analysis. For example, WHO
(2011a, 2011b) notes that, worldwide, an estimated
8 million children under 5 years of age die every year and
358,000 women die each year as a result of pregnancy
and childbirth. Over the past century, however, the focus
on health has shifted to disease prevention, health promotion, and wellness. Since 1948, WHO has defined
health as a state of complete physical, mental, and social
well-being, and not merely the absence of disease or
infirmity (WHO, 2008).
The definition of health is complex; it is not merely
the absence of disease or an analysis of mortality and morbidity statistics. Focusing on the health of the population
has resulted in research to determine what factors contribute to making the population healthy and unhealthy.
The determinants of health include social and economic
conditions that influence health. One significant determinant is healthy child development, which is influenced by
family income and social status, parental education, culture, and social supports (Hamilton & Bhatti, 1996;
PHAC, n.d). In October 2005, the federal, provincial and
territorial Ministers of Health agreed on an overarching
goal for every Canadian to be as physically, mentally,
emotionally, and spiritually healthy as possible. This broad
goal was further divided into more specific objectives, the
first of which was that Canadian children reach their full
potential and that they grow up to be healthy, confident,
secure, and happy (PHAC, 2006).
One significant public health concern is obesity: 26%
of Canadian children ages 2 to 17 are overweight and 8%
are obese (Shields, 2006). Two major factors contributing
to childhood obesity are inactivity and the amount of time
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Chapter 1
Mortality
Mortality is the incidence or number of individuals who
have died over a specific period. This statistic is presented
as rates per 100,000 and is calculated from a sample of
death certificates. Statistics Canada collects, analyzes,
and disseminates the data on Canadas mortality rates
(Statistics Canada, 2010).
Maternal Mortality
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over the past 30 years, and the MMR has decreased from
422 deaths in 1980 to 251 deaths in 2008 (Brunner,
2010). However, Canadas MMR has increased from
6 in 1990 to 12 in 2009. The federal government has
pledged to improve maternalchild care outcomes and
thus reduce mortality rates for women and children.
Canada is one of the most medically and technologically
advanced nations and has one of the highest per capita
rates for health care spending in the world (Kaiser Family Foundation, 2011), but the current mortality rates
indicate the need for improvement. For example:
There has been a rise in the MMR related to atonic
postpartum hemorrhage (PPH, 33.8 deaths in 1995
versus 38.7 in 2005).
There has been a rise in MMR related to PPH with
hysterectomy (35.1 deaths in 1995 versus 40.7 in
2005) (PHAC, 2008).
The maternal morbidity and mortality rates among
Aboriginal women are dismal (National Aboriginal Health
Organization [NAHO], 2008). Stillbirth and perinatal
death rates among [Aboriginals] are about double the
Canadian average; among Inuit living in the Northwest
Territories, they are about two and a half times the Canadian average (NAHO, 2008, p. 16). In 1993 (latest information available), the Aboriginal postnatal mortality rate
was approximately three and a half times the national rate
(NAHO, 2008). In 2003, the breastfeeding rate in the
Aboriginal population was 60% compared with 75% in
the rest of the population (Stout & Harp, 2009).
In a 2005 roundtable on Aboriginal womens and
girls health hosted by NAHO, the following priority
issues for womens reproductive and maternal health were
identified:
Lack of culturally appropriate supports and facilities
for pregnancy and birth
Lack of culturally appropriate education, training, and
support for Aboriginal midwives
Inadequate funding and bursaries to support training
Long waiting lists to access midwives
Liability issues for midwives (NAHO, 2008)
Immigrant women may also receive subpar prenatal
care, which may be explained by language, cultural, and
legal barriers. Further studies are needed to identify and
eliminate the disparities in health service provision to this
population. Women living in rural settings also have
difficulty accessing adequate care.
Fetal Mortality
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fetal factors (e.g., congenital anomalies, placental abruption, infection, umbilical cord accidents). Over 25% of
stillbirths are due to unknown causes. Fetal mortality provides an overall picture of the quality of maternal health
and prenatal care.
Take Note!
The Aboriginal peoples of Canada,
including the First Nations, Inuit, and
Mtis, have consistently had higher infant mortality
rates than other ethnic groups (UNICEF Canada,
2009).
LBW and prematurity are major indicators of infant
health and significant predictors of infant mortality
(PHAC, 2008). The leading cause of infant death in
Canada is prematurity followed by congenital anomalies,
asphyxia, and respiratory distress syndrome (PHAC,
2008).
After birth, primary health prevention strategies can
significantly improve an infants health and chances of
survival. Breastfeeding has been shown to reduce rates of
infection in infants and to improve their long-term health.
Emphasizing the importance of placing an infant on his
or her back to sleep will reduce the incidence of sudden
infant death syndrome (SIDS). Encouraging mothers to
join support groups to prevent postpartum depression
and learn sound childrearing practices will improve the
health of both mothers and their infants.
Childhood Mortality
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Morbidity
Morbidity is the measure of the prevalence of a specific
illness in a population at a particular time. It is presented
in rates per 1,000 population. Morbidity is often difficult
to define and record because the types of measurement
used vary widelyfor example, visits to the physician or
diagnosis for hospital admission. Information may be
difficult to obtain, such as that gathered by household
interviews from research studies. Morbidity statistics are
revised less frequently because of this difficulty in defining or obtaining the information.
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Chapter 1
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BOX 1.2 Milestones in Support of the Health of Women and Children (continued)
1996 The Womens Health Contribution Program
was created to support community and
academic partnerships in development
and dissemination of policy research and
information on womens health.
1998 Women and Health Care Reform was
created as a Working Group from funding
by the Womens Health Contribution Program, a Bureau of Womens Health and
Gender Analysis at Health Canada.
1999 The Social Union Framework Agreement
was signed, recommitting the country to
comprehensiveness, universality, portability, public administration, and accessibility to health care services.
2003 The First Ministers Accord on Health Care
reaffirmed the five primary principles of
the Canada Health Act.
2004 The Multidisciplinary Collaborative
Primary Maternity Care Project (MCP2),
a nationwide initiative to address the
looming shortage of skilled health care
professionals in the maternity field, was
Aboriginal health
AIDS
Breast health (i.e., cancer and breast implants,
mammography)
Cancer, particularly lung, breast, and cervical cancer
Complications of pregnancy
Chronic disease, particularly allergies, arthritis, back
and limb problems, urethral conditions
Diabetes
Family violence and sexual abuse
Heart disease and stroke
Lesbian health
Medication use
Mental health issues, particularly depression
Menopause and the use of hormone replacement
therapy
Worklife balance
Source: Public Health Agency of Canada. (2003). Womens health surveillance report. Retrieved February 8, 2012 from http://www.phac-aspc.
gc.ca/publicat/whsr-rssf/.
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Chapter 1
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Childhood Morbidity
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with a serious trauma, 20% of which are serious head injuries. In 2008, for every 100,000 children hospitalized, 348
were hospitalized due to unintentional injury, including
falls, poisoning, suffocation, and burns (Government of
Canada, 2008). Cancer is rare in children but it is the leading cause of disease-related death in Canadian children,
with the highest incidence in preschool years (Government of Canada, 2008). Common health problems in
children include respiratory disorders, such as asthma
and allergies; gastrointestinal disturbances, which lead
to malnutrition and dehydration; and injuries. As more
immunizations become available, common childhood
communicable diseases affect fewer children. Another
trend is an increase in the number of children with mental
health disorders and other emotional, social, or behavioural problems. The number of Canadian children
impacted by mental health disorders is 1.2 million, or
15% of the pediatric population (Canadian Council on
Learning, 2009). These conditions can interfere with childrens social and academic development and may also
increase the risk for significant mental health problems
later in life. Adolescents with mental health disorders are
more likely to experience injury secondary to reckless
driving, promiscuous sexual activity, and substance abuse.
Take Note!
Environmental and psychosocial factors are
now an identified area of concern in the morbidity of children.The new morbidities in children
include academic difficulties, complex psychiatric disorders, increased incidence of self-harm and harm to others, use of firearms, hostility at school, substance abuse,
HIV/AIDS, and adverse media influences (Reasor &
Farrell, 2004).
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include increasing numbers of new immigrants and refugees. As a result, nurses must have a more globalized focus
on health and mental health as well as an awareness of the
types of situations that children may have encountered in
refugee camps or war-torn countries.
Across Canada, access to physicians and social supports has changed due to modifications in health care
delivery and financing. Nurses are playing an increasingly important role in addressing health needs in situations that were traditionally attended to by physicians.
Maternity, pediatric, and community health nurses have
assumed a frontline role in:
Primary prevention, through initiatives to promote
health and prevent disease by identifying and addressing modifiable risk factors. Examples are immunization clinics and promotion of breastfeeding.
Secondary prevention, through early detection and
treatment of health concerns. An example is a pediatric nurse assisting a child who has observed domestic
violence but who does not show any signs of personal
injury (Wolfe & Jaffe, 1999).
Tertiary prevention, by ensuring that appropriate
interventions for illnesses and diseases for high-needs
populations are identified and met.
While demographics, genetics, and other health indicators can affect people in a positive way and contribute
to healthy growth and development, in some situations
they exert a negative influence by increasing a persons
health risks. Nurses, especially those working with women
and children, need to understand how these influences
affect the quality of nursing care and health outcomes.
They must examine the impact of these variables to gain
the knowledge and skills needed to work with families
and populations to develop the best plan for effective
care, thereby achieving the best possible outcomes for
women, children, and families.
Family
The family is considered the basic social unit. Todays
families do not fall under a single definition, and the
definition of family is changing to reflect todays structural and functional changes. Canada conforms to internationally recognized standards for the definition of
family (Statistics Canada, 2009a), which can be summarized as a group of two or more persons related by
birth, marriage, or adoption and living together. While
earlier definitions of family emphasized the legal ties or
genetic relationships of people living in the same household with specific roles, Wright and Leahey (2005), formerly of the Family Nursing Unit at the University of
Calgary, define family as whatever the people involved
say it is for them.
The family greatly influences the development and
health of its members. For example, children learn health
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Chapter 1
Table 1.1
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Theory
Description
Key Components
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Table 1.2
Theory
Description
Key Components
Nuclear family
Binuclear family
Child who is a member of two families due to joint custody; parenting is considered a joint
venture
Single- or lone-parent
family
Commuter family
May lead to family conflict due to different expectations on the part of the child and adults; they may
have different views and practices related to child
care and health
Extended family
Communal family
Foster family
Grandparents-as-parent
families
Adolescent families
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Chapter 1
Take Note!
Family Structure
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The lifestyle of the parents basically is the lifestyle of the children. For instance, parents who
are inactive and eat poorly will have children
who do the same, and the problems associated with these
unhealthy habits, such as diabetes, obesity, and early
heart disease, are showing up earlier in children and adolescents. It is important for parents to serve as role models
for proper nutrition and physical activity (through sports,
hobbies, or other activities).
Figure 1.3 Nurses must take into account family dynamics when
providing health care. There are many different family structures,
and they influence the clients needs. (A) The traditional nuclear
family is composed of two parents and their biological or adopted
children. (B) The extended family includes the nuclear family
plus other family members, such as grandparents, aunts, uncles,
and cousins. (C) Gay and lesbian families comprise two people
of the same sex sharing a committed relationship with or without
children.
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Chapter 1
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Chapter 1
Children in foster care have higher than average medical, emotional, developmental, and educational needs,
some of which include:
Physical health problems
Self-blame and feelings of guilt
Feelings of being unwanted
Feelings of helplessness
Insecurity and uncertainty about the future
Ambivalent feelings related to foster parents; feelings
of being disloyal to birth parents (American Academy
of Child & Adolescent Psychiatry, 2005)
Genetics
Genetics (the study of heredity and its variations) has
implications for all stages of life and all types of diseases.
The childs biological traits, including gender, race, some
behavioural traits, and the presence of certain diseases or
illnesses, are directly linked to genetic inheritance. New
technologies in molecular biology and biochemistry have
led to a better understanding of the mechanisms involved
in hereditary transmission, including those associated
with genetic disorders. These advances are leading to better diagnostic tests and better management options.
Gender
Race
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Society
Society has a major impact on the health of women, children, and families. Major influences include social roles,
socioeconomic status, the media, and the expanding
global nature of society. Each of these may influence a
persons self-concept, where he or she lives, the lifestyle
he or she leadsand thus his or her health.
Social Roles
Socioeconomic Status
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Poverty is a measurement based on the specific monetary income of a family. The poverty threshold is often
measured as a set dollar amount that the government uses
to determine whether a family is living in poverty. Poverty
in Canada is most commonly measured using the Statistics Canadas low-income cut-off (LICO), which is based
on a family spending 20% more of its income on household necessities than the average Canadian family (Human
Resources and Skills Development Canada, 2006). LICO
is not an absolute number and varies depending on the
number of dependents and the population of the community or city. If the individuals or familys income is at or
below LICO, then that person or family is said to be living
in poverty. Approximately one in six children in Canada,
or just over a million, lives in poverty; of those, about 75%
live below LICO. The Canadian National Longitudinal
Study of Children revealed that the number of children
considered to be vulnerable, including vulnerability related
to poverty, stands at about 28% (Health Canada, 2007;
Statistics Canada, 2007). It is noteworthy that the same
children did not necessarily remain vulnerable. With each
survey approximately 15% of the formerly vulnerable children no longer met the criteria. However, a new 15% of
children had become vulnerable.
Despite the many global economic gains that have
been made during the past century, poverty continues to
grow and the gap between rich and poor is widening.
Major gaps continue between the economic opportunities
and status afforded to women and those offered to men. A
disproportionate share of the burden of poverty rests on
womens shoulders, and this undermines their health.
However, poverty, particularly for women, is more than
monetary deficiency. Women continue to lag behind men
in control of cash, credit, and collateral. Other forms of
impoverishment may include deficiencies in literacy, education, skills, employment opportunities, mobility, and
political representation, as well as pressures on time and
energy linked to their responsibilities. These poverty factors may affect a womans health (Coll-Back, Bhushan, &
Fritsch, 2007).
The effects of poverty on childrens health can be
wide-ranging. The child may live in substandard housing
or housing that poses a threat to his or her health (e.g.,
unsanitary conditions, exposure to toxins, exposure to
violence). Poverty may lead to homelessness for the family. Children living in poverty are more likely than other
children to be poorly nourished, to have inadequate health
care, to become teen parents, and to have insufficient education. Children living in poverty are also at increased risk
for experiencing abuse and violence (Health Canada,
2007).
Homelessness
Homelessness is defined as living in a shelter, on the street,
or in other places not intended for human habitation.
This includes couch surfing (i.e., staying temporarily
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Chapter 1
25
Media
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Violence
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Chapter 1
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Take Note!
Not all children exposed to violence suffer
negative consequences. Children are resilient,
and preliminary studies indicate that protective factors,
such as involvement in social activities, a strong commitment to school and academic performance, and the ability to discuss problems with a supportive adult, can
buffer children from the effects of violence, thereby helping to reduce the risk of developing violent behaviours.
Community
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School rules about attendance and authority relationships and the system of sanctions and rewards based on
achievement transmit to children behavioural expectations that will help them succeed in employment, relationships, and self-sufficiency as adults. Schools can also
play a major role in improving health and encouraging
healthy behaviours. For example, some Canadian schools
offer programs that identify school strengths related to
health and health promotion; through groups that include
students, parents, school staff, and community health
nurses, these programs develop and deliver action plans
to address desired next steps to improve the health and
well-being of the school population. One such program is
the Comprehensive School Health program in Calgary,
Alberta (Alberta Health Services, 2011).
Because of social changes in Canada and elsewhere,
more children are in child care and after-school programs than ever before. Thus, the socialization process
begins earlier and involves a larger percentage of the
childs waking hours (Fig. 1.7). Community centres and
after-school programs can provide support, empowerment, boundaries and expectations, and constructive use
of time (Search Institute, 2011).
Peer Groups
Peer groups can have a great impact on children. Relationships with peers often begin early, and they continue
to be a large part of the childs world, particularly in
school-age children and adolescents. This influence starts
in play groups in early preschool or elementary school.
The child comes into contact with a variety of values and
belief systems from interactions with peer groups. When
these values and beliefs differ from those of the childs
family, conflicts can occur, possibly separating children
from parents and strengthening the bond with the peer
group. When the peer group is involved with school activities, athletics, or other healthy behaviours, the influence
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Culture
Culture is a view of the world and a set of traditions that
are used by a specific social group and are transmitted
to the next generation. Culture plays a critical role with
women, children, and families. A persons culture influences not only socialization but also his or her experiences
related to health and specific health practices. Culture is a
complex phenomenon involving many components, such
as beliefs, values, language, time, personal space, and view
of the world, all of which shape a persons actions and
behaviour. Individuals learn these patterns of cultural
behaviours from their family and community through a
process called enculturation, which involves acquiring
knowledge and internalizing values. Culture influences
every aspect of development and is reflected in childbearing and childrearing beliefs and practices designed to promote healthy adaptation.
With todays changing demographic patterns, nurses
must be able to assimilate cultural knowledge into their
interventions so they can care for culturally diverse women,
children, and families. Nurses must be aware of the wide
range of cultural traditions, values, and ethics. Cultural
safety is an approach in which nurses are encouraged to
recognize that they will never fully understand another
persons culture and way of life because cultures and people are complex. People are a blend of many cultures (ethnicity, age, gender, occupation, socioeconomic status, etc),
7/5/12 5:13 PM
Chapter 1
and the relationship between these cultures is fluid, interactive, and dynamic.Therefore, the culturally safe approach
is for nurses to acknowledge that they cannot fully predict
or standardize a clients cultural needs; however, nurses
can create an environment in which the client feels culturally safe. Cultural safety is defined by the person receiving
care and not by the nurse; in this way the health care provided can be adapted to meet the clients or patients needs.
Nurses also need to recognize the strengths and capabilities that the patient or client possess that derive from their
culture. These need to be acknowledged and incorporated
when helping the individual or family develop self- or
home management strategies. This approach requires that
nurses first examine and reflect on their own culture and
biases. For example, nurses should contemplate what they
consider to be desirable universal moral principles and
then think about how they would intervene with a patient
whose moral principles are different from their own. In
hospitals, patients are already in a position of vulnerability
in that they require care they cannot provide for themselves and they are separated from their own cultural contexts. As part of the dominant hospital culture, it is
incumbent on nurses to ask the patient or family about
cultural preferences. Cultural safety occurs when nurses
respond in a way that preserves the patients identity and
that the patient regards as culturally appropriate (Woods,
2010).
Take Note!
One suggestion to assist in preparing to provide culturally safe care is for nurses to list
their desirable universal moral principles and then
consider how they would intervene with a patient whose
moral principles are different from their own.
Cultural Groups
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29
Take Note!
Nurses can have a lifelong influence on an
individuals perceptions of health and use of
health services. By providing culturally safe care, nurses
can enhance the familys traditional practices, and different cultural practices can become sources of strength
rather than areas of conflict.
7/5/12 5:13 PM
Table 1.3
Cultural Group
African
Strong extended family relationships; mother as head of household; older family members valued
and respected
Food as a symbol of health and wealth
View of health as harmony with nature; illness as disruption in harmony
Use of folk healing and home remedies common
View of pregnancy as a state of wellness
Emotional support during labour commonly from other women, primarily the womans own mother
Liberal use of oil on newborns and infants scalp and skin
Belief in illnesses as natural (due to natural forces person hasnt protected self against) and
unnatural (due to person or spirit)
Illness commonly associated with pain
Pain and suffering inevitable; relief achieved through prayers and laying on of hands
Individuals vulnerable to external forces
Asian
Arab
Aboriginals (First
Nations)
Hispanic
30
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Chapter 1
Though the word religion is often used interchangeably with spirituality in our society, the two are distinctly different. Spirituality is considered private and
individual. Religion, in contrast, is an organized way of
sharing beliefs and practicing worship. Less than 75% of
Canadians state that they believe in a god (Avery, 2008).
This contrasts sharply with the United States, where only
8% do not believe (Avery, 2008). Canadians with spiritual
or religious beliefs and views find that they provide
strength and support during times of stress and illness. In
some religions, illness is seen as a punishment for sin or
wrongdoing. Others religions view illness as a test of
strength that allows them to strive for faithfulness. Spirituality in Canada cannot be measured or understood solely
in terms of organized religion; interest in the afterlife and
spiritual references are found in many popular books and
movies (Harvey, 1998).
Identifying a clients religious beliefs and customs is
important. Families appreciate recognition of and respect
for their beliefs. Dietary restrictions, rituals such as baptism or communion, use of amulets or icons, or practices
related to birth or newborn care can be incorporated into
the plan of care. The best way to meet a familys spiritual
needs is to ask them about their preferences and ensure
that they are clearly communicated to health care staff
interacting with the family.
Take Note!
Never make assumptions about a familys
religious or spiritual affiliation. Although they
may belong to a particular religion, they may not adhere
to all of its beliefs or participate in all aspects of the religion. Ask the family about their beliefs and preferences,
and be alert for clues that provide insight into their specific beliefs.
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31
World countries are decreasing their immigrant numbers due to economic downturn. Becoming a Canadian
citizen is seen to be more difficult. In 2009, the federal
government toughened the citizenship testing. As many
as one third of immigrants failed the test that year,
compared with 4% to 8% in previous years (Guneet,
2010).
Canada is viewed as offering employment and economic opportunities, expanded human rights, educational opportunities, and other types of freedoms and
opportunities, thus inspiring many individuals to move
to Canada from other countries. Immigration significantly affects the health, educational, and social services
offered in this country. It also presents issues related to
access to care and the types of care that need to be
offered. Canada continually evaluates and amends its
immigration policies.
Immigration imposes unique stresses on women,
children, and families, including:
Depression, grief, or anxiety associated with migration
and acculturation
Separation from support systems
Inadequate language skills in a society that is not tolerant of linguistic differences
Disparities in social, professional, and economic status
between the country of origin and Canada
Disparities between what the new immigrant anticipated when moving to Canada and reality
Traumatic events such as war or persecution that may
have occurred in the immigrants native country
(American Academy of Pediatrics Committee on
Community Health Services, 2005)
Immigrant families may face financial, language, cultural, and other type of barriers that reduce their ability to
access health care. For example, they may not seek care if
they cannot find health care providers who speak their
language or are not confident an interpreter will be available. Stresses experienced by immigrant children and
their families, such as those associated with relocation,
separation, and traumatic events, can also affect their psychological health. See Evidence-based Practice 1.2.
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U nit o n e
Source: Grewal, S.K., Bhagat, R., & Balneaves, L.G. (2008). Perinatal beliefs and practices of immigrant women living in Canada. Journal of Obstetric, Gynecologic and Neonatal Nursing, 37(3).
Developmental level has a major impact on an individuals health status. In general, the distribution of diseases
LWBK1091-C01_p01-49.indd 32
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Chapter 1
33
Nutrition
Lifestyle Choices
LWBK1091-C01_p01-49.indd 33
B
Figure 1.8 (A) The dietary habits established early in life can
have a long-lasting impact on the childs health and quality of
life. (B) This pregnant client is eating a healthy meal to ensure
adequate nutrition.
Environmental Exposure
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U nit o n e
LWBK1091-C01_p01-49.indd 34
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Chapter 1
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35
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36
U nit o n e
acute care referral centre. If the weather is uncooperative, or the air ambulance is busy, it may be many hours
before the patient can be transported (Canadian Association of Emergency Physicians, n.d.).
Aboriginal people who live on reservations and Inuit
living in the North have direct health services provided
and paid for by the federal government and not under
the jurisdiction of the provinces. Like all Canadians, they
receive health services under the Canada Health Act, but
additional services are provided and paid for by Health
Canada rather than the province in which a reserve is
located. As a result, First Nations people experience different health services and restrictions if they are living on
or off the reservation. In the mid-1980s, Health Canada
began working with the First Nations and Inuit communities to transition control of health services from the
government to the Band councils. The pace of the transition is dependent on each Band councils accountability
(Health Canada, 2011a).
Similar models of community intervention have been
implemented in First Nations, Inuit, and Aboriginal communities with the addition of a 1-day training program
designed to improve the health professionals ability to recognize psychological distress. Evaluation results for this
program reveal that suicide rates among youth ages 15 to
19 years were reduced shortly after implementation and
sustained for the ensuing 5 years (Health Canada, 2005).
Many attribute Canadas life expectancy (about 80
years) and low infant mortality rate to its universal health
care system. Canadian citizens of all income levels and at
all stages of life can seek health care for early treatment,
maintenance, and preventive interventions without concern about cost (Canadian Health Care, 2007). The
most significant issue is the variation in accessibility,
which is dependent on factors such as isolation and provincial budgets.
LWBK1091-C01_p01-49.indd 36
Improvements in Diagnosis
and Treatments
Because of the tremendous improvements that have been
made in technology and biomedicine, disorders and diseases are being diagnosed and treated earlier. The 1990s
witnessed remarkable advances in identifying connections
between genetics and various pathophysiologic processes.
For example, a female fetus with congenital adrenal hyperplasia, a genetic disorder resulting in a steroid enzyme deficiency that can lead to disfiguring anatomic abnormalities,
can now receive treatment before birth. In addition, many
genetic defects are being identified so counselling and
treatment may occur early. With these improved diagnoses
and treatments, nurses may now be caring for individuals
who have survived situations that once would have been
fatal, who are living well beyond their life expectancy for a
specific illness, or who are functioning with chronic disabilities. For example, at one time women with congenital
heart disease did not live long enough to become pregnant.
However, with new surgical techniques to correct the
defects, many of these women survive and become pregnant, progressing through their pregnancy and delivery
without significant problems.
While positive and exciting, these advances and trends
also pose new challenges for the health care community.
For example, as health care for premature newborns
improves and survival rates increase, the incidence of
long-term chronic conditions such as respiratory airway
dysfunction or developmental delays has also increased.
As a result, nurses are faced with caring for clients at all
stages along the healthillness continuum.
Empowerment of Health
Care Consumers
Due to the influence of the media as well as the PHAC,
the focus on prevention, a more educated population,
and technological advances, individuals and families have
taken an increased responsibility for their own health.
Health consumers are now better informed, and they
play a greater role in managing their own health and illness. Families seek information about illnesses, and they
participate in making decisions about treatment options.
As client advocates valuing family-centred care, nurses
are instrumental in promoting this empowerment. To do
this effectively, the nurse must respect the familys views
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Chapter 1
Transportation
Getting to and from appointments can be challenging for
clients who do not drive or own a car or cannot use public
transportationif there is public transportation in the
area. It can be difficult for these clients to attend all recommended prenatal health care visits or well-child visits,
especially if the woman has other small children who must
be taken along on the visit. These challenges can reduce
the adherence to scheduled appointments and follow-up.
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37
Human Resources
Consider This!
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38
U nit o n e
Abortion
Abortion has always been a volatile legal, social, and
political issue. In 1969, the Criminal Code of Canada
was amended to decriminalize abortions performed by
physicians in hospitals after a therapeutic abortion
committee determined that the womans health would
be negatively impacted by continuation of the pregnancy. In 1981, Quebec established abortion clinics as
part of its community services. In 1988, the Supreme
Court deleted abortion from the criminal code, leaving
decisions around care of women requesting an abortion
to each provincial health care system. In 1991, the
Supreme Court ruled that an unborn child is not a person and unborn children have no rights unless they are
born alive. In 1999, nurses at Markham Stouffville Hospital in Ontario set a Canadian precedent when they
were given the right to decline assisting doctors in performing abortions.
Although abortion is a common procedure in Canada today, it remains a hotly debated political issue that
separates people into two camps: pro-choice and prolife. The pro-choice group supports the right of any
woman to make decisions about her reproductive functions based on her own moral and ethical beliefs. The
pro-life group feels strongly that life starts at conception and abortion is murder, as it deprives the fetus of
the basic right to life. In recent years, several parliamentary bills have been introduced, but not passed,
that would make it illegal to perform abortions after 20
weeks gestation and making it a separate crime to kill a
fetus in the course of a violent attack on a mother. This
very emotional issue will continue to be debated years
to come (AbortionInCanada.ca., n.d.; LifeCanada,
2008).
Medical and surgical modalities are available to
terminate a pregnancy, depending on how far the pregnancy has developed. A surgical intervention can be
performed up to 14 weeks gestation; a medical intervention can be performed up to 9 weeks gestation
(Gan, Zou, Wu, et al., 2008). All women undergoing
abortion need emotional support, a stable environ-
LWBK1091-C01_p01-49.indd 38
Substance Abuse
Substance abuse for any person is a problem, but when
it involves a pregnant woman, substance abuse can
cause fetal injury and thus has legal and ethical implications. In some instances, courts have issued jail sentences
to pregnant women who caused harm to their fetuses
(LifeCanada, 2008). Many provincial laws require nurses
to report evidence of prenatal drug exposure, which may
lead to charges of negligence and child endangerment
against the pregnant woman. This punitive approach to
fetal injury raises ethical and legal questions about the
degree of governmental control that is appropriate in the
interests of child safety (AbortionInCanada.ca., n.d.).
Many services are available to assist a pregnant woman to
eliminate substance abuse in pregnancy.
Fetal Therapy
Intrauterine fetal surgery is a procedure that involves
opening the uterus during pregnancy, performing surgery on the fetus, and placing the fetus back in the uterus.
Although the risks to the fetus and the mother are both
great, fetal therapy may be used to correct some anatomic
lesions (Noble & Rodeck, 2008). Nurses play an important supportive role in caring and advocating for clients
and their families. As the use of technology grows, situations will surface more frequently that test a nurses belief
system. Encouraging open discussions to address emotional issues and differences of opinion among staff members is healthy and increases tolerance for differing points
of view.
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Chapter 1
Informed Consent
Informed consent has four key components: disclosure,
comprehension, competency, and voluntariness (Taylor,
Lillis, & LeMone, 2005). It occurs prior to initiation of
the procedure or specific care and addresses the legal and
ethical requirement of informing the client about the procedure. The physician or advanced practice nurse is
responsible for informing the client about the procedure
and obtaining consent by providing a detailed description of the procedure or treatment, its potential risks and
benefits, and alternative treatments available. If the client
is a child, typically this information is provided to the parents or legal guardians. The nurses responsibility related
to informed consent includes:
Ensuring that the consent form is completed with signatures from the client (or parents or legal guardians
if the client is a child)
Serving as a witness to the signature process
Determining whether the client or parents or legal
guardians understand what they are signing by asking
them pertinent questions
Although laws vary between provinces, certain key
elements are associated with informed consent (Box 1.5).
Nurses need to be familiar with their specific provincial
laws as well as the policies and procedures of the health
care agency. Treating clients without obtaining proper
consent may result in charges of assault, and the health
care provider and/or facility may be held liable for any
damages.
Generally, only people over the age of majority (18
years of age) can legally provide consent for health care.
Since children are minors, when care is rendered to
them, the process involves obtaining written permission
from a parent or legal guardian. In cases requiring a sig-
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39
Take Note!
Allow older children and adolescents to be
involved in the decision-making process to the
extent possible. However, keep in mind that the parent or
guardian is still ultimately responsible for giving consent
to treatment.
Most care rendered in a health care setting is covered by the initial consent for treatment signed when the
individual becomes a client at that office or clinic or by
the consent to treatment signed upon admission to the
hospital or other inpatient facility. Certain procedures,
however, require a specific process of informed consent:
major and minor surgery; invasive procedures such as
amniocentesis, internal fetal monitoring, lumbar puncture, or bone marrow aspiration; treatments placing the
client at higher risk, such as chemotherapy or radiation
therapy; procedures or treatments involving research;
and photography involving the client. Applying restraints
to children now requires consent.
If the client cannot provide consent, or in the case of
a child, the parent or guardian is not available, then the
person closest to the client or in charge of the child (relative, babysitter, or teacher) may give consent for emergency treatment if he or she has a signed form from the
parent or legal guardian allowing him or her to do so.
During an emergency situation, a verbal consent, via the
telephone, may be obtained. Two witnesses must also be
listening simultaneously and must sign the consent form,
indicating that consent was received via telephone.
Health care providers can provide emergency treatment
to a child without consent if they have made reasonable
attempts to contact the childs parent or legal guardian.
Table 1.4 provides additional information about the
informed consent process with children.
Take Note!
Never assume that the adult accompanying
the child is the custodial parent or legal
guardian. Always clarify the relationship of the accompanying adult.
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40
U nit o n e
Table 1.4
Issue
Definition
Nursing Considerations
Child is living:
In foster care
With potential adoptive parent
With a relative
Need to comply with all federal regulations if federal funds received (see discussion of assent in
text)
LWBK1091-C01_p01-49.indd 40
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Chapter 1
be obtained as a mature minor (without parental consent). According to provincial law, health care may be
provided to minors for certain conditions, in a confidential manner, without notifying the parents. These types
of care may include pregnancy counselling, prenatal
care, contraception, and testing and treatment for sexually transmitted infections. These exceptions provide a
confidential environment for children who would avoid
care if they were required to inform their parents or legal
guardian. Again, the laws vary by province so nurses
must be knowledgeable about the laws in the province
where they practice.
Additional situations in which persons under the age
of 18 are frequently assessed as mature minors include:
Marriage
Financial independence and separate living arrangement from parents
Pregnancy
Mother of an infant/child less than 18 years of age
Teen request for birth control (Alberta Health
Services, 2010)
Nurses must be familiar with laws of the province in
which they work so they can be in compliance when rendering health care and treatment.
Assent
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41
Clients Rights
Canada does not have a patients bill of rights. One was
presented to the federal government in 2002, but it was
not passed as the majority of the members of Parliament
felt that legal precedent has established that the facility or
health care organization providing care has a responsibility to the patient (Government of Canada, 2002). Some
established rights of patients in Canada include the right
to confidentiality; the right to complete, current information concerning the diagnosis in language that the patient
can comprehend; and the right to expect patient safety.
The CNA (2008) defines patient safety as not only the
prevention and mitigation of unsafe acts within the
health care system, but also being under the care of a
health care provider who, with the persons informed
consent, assists the patient to achieve an optimum level of
health (p. 1). The Canadian Institute of Child Health
(n.d.) published the Rights of the Hospitalized Child in
1980 to raise awareness of the issues faced by hospitalized children. These included the right to be viewed first
as a child and then as a patient, the right to be afraid and
to cry if hurt, the right to have those dear to them close
by when needed, and the right to play and learn even
while receiving health care.
Ensuring that clients rights are upheld is a key aspect
in the care of any client. For the pregnant woman, two
clients must be consideredthe pregnant woman and her
fetus. A child, due to his or her age and developmental
level, may lack mature decision-making abilities. Many
pediatric institutions have adopted a bill of rights for childrens health care specific to that institution (Box 1.6).
Parents or legal guardians are ultimately the decision makers for their children. In ethical dilemmas such
as babies born with brain damage or extremely preterm
birth, parents must be accurately informed about the
risks and benefits of treatment before giving consent to
treatment or deciding to withdraw or forego treatment
(Hurst, 2006; Janvier, Barrington, Aziz, et al., 2008).
Some professionals are advocating for prenatal advance
directives that would guide care from the time of birth of
an extremely premature or otherwise impaired term
infant (Catlin, 2005; Janvier et al., 2008).
Confidentiality
The Freedom of Information and Protection of Privacy
Act in Alberta, Ontario, and other provinces legislated
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42
U nit o n e
LWBK1091-C01_p01-49.indd 42
Key Concepts
77 Maternal and child health nurses provide care using a
philosophy that focuses on the family as the emphasis
of care, providing atraumatic care and using evidencebased practice in a case management environment to
provide quality, cost-effective care.
77 Health Canada, as well as provinces and territories,
have health goals and objectives for adults and children that focus on health promotion and disease
prevention.
77 One method to establish the aggregate health status of
women, infants, and children is with statistical data,
such as mortality, morbidity, and low birth weight
rates.
77 The infant mortality rate, although lower in Canada
than in many countries in the world, is on the rise.
This may be the result of the increase in low-birthweight infants born in Canada. The low birth weight
7/5/12 5:13 PM
Chapter 1
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Chapter 1
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Recommended Readings
American Pregnancy Association. (2011). Doing it alone. Retrieved
February 8, 2012 from http://www.americanpregnancy.org/
unplannedpregnancy/doingitalone.html
Canadian Cancer Society. (2011). Cancer statistics figures. Retrieved
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Canadian Institute for Health Information. (2009). Highlights of 2008
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Chapter Worksheet
Multiple Choice Questions
1. When preparing a presentation for a local womens
group on womens health problems, what would the
nurse include as the number-one cause of mortality
for women in Canada?
a. Breast cancer
b. Childbirth complications
c. Injury resulting from violence
d. Heart disease
2. Which factor would most likely be responsible for a
pregnant womans failure to receive adequate prenatal care in Canada?
a. Age of the pregnant woman
b. Use of denial to cope with pregnancy
c. Shortage of health care professionals such as physicians and midwives in their community
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Study Activities
1. Research a current policy, bill, or issue being debated
in the community, within your nursing association, or
at the provincial or federal government level that pertains to the health and welfare of women or children.
Summarize the major facts and supporting and
opposing arguments, and prepare an oral report on
your findings.
2. Interview a child life specialist about the effects of
using the atraumatic approach or the traditional
approach for restraining children during procedures.
Compare and contrast the effects on children at various developmental stages.
3. Within your clinical group, debate the following
statement: Should access to medications and auxiliary health care such as physiotherapy outside a hospital be a right or a privilege?
4. Visit a local community health centre that offers services to women and children from various cultures.
Interview the staff about any barriers to health care
that they have identified. Investigate what the staff
has done to minimize these barriers.
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