First 1,000 Days Integrated Care Pathway
Dr. Sylvanus Nawab and Minister of Health Kim Wilson provided an update on the First 1,000 Days Integrated Care Pathway.
Dr. Sylvanus Nawab’s statement follows below:
“Thank-you Minister Wilson and good morning. The first five years of a child’s life is the time within which their brains are developing rapidly – their brain cells are connecting to enable movement, language, emotion, and other essential functions. Brain connections needed for higher-level abilities, such as self-regulation, problem-solving, self-esteem, and communication are being made. It’s also a time where their daily life experiences truly matter. As Minister Wilson indicated, proper health care from birth into their earliest years is crucial for a child’s overall health and well-being. I am pleased to share with you the findings that have come out of the First 1,000 Days Integrated Care Pathway initiative to date. In Bermuda, maternal and child health services are spread across several providers in both the private and public sectors. Services include, but are not limited to, antenatal, pregnancy, and breastfeeding classes; doulas; OBGYNs; postnatal care; maternal health; paediatric services; immunisation; child development; and early intervention. Through the Pathway Mapping exercise, 10 challenges were identified and are included in the final report.
- The exchange of health-related information between healthcare providers, patients, and across various healthcare settings is ineffective and creates challenges for those receiving care.
- Feedback from the patient interviews and community survey reflects a lack of consistency in the amount of antenatal care information provided to women across providers, which can impact patient experience. In particular, women who are under- or uninsured may not be aware that antenatal care is available at no cost through public clinics, which has led to late presentation of pregnancy – in the second and third trimesters.
- Access to maternal and child health services remains a challenge for many. Financial constraints and the limited availability of specialised care can impede individuals’ ability to receive timely and equitable healthcare services.
- Options for affordable childcare are limited and affect women’s economic opportunities. If a mother cannot afford childcare, she may be prevented from re-entering the workforce because she needs to stay home and care for her child. It can also impact a child’s cognitive development – for the mother who is out working two to three jobs to cover childcare and other necessary expenses, the child is missing time with their mother and the cognitive development that comes with a result of that time together.
- The current antenatal model of care is often perceived as outdated by both patients and providers.
- Care is fragmented across the Island, mostly due to lack of communication between providers, both in the public and private sectors. Further, the lack of an electronic health record increases the challenge of coordinating care.
- The current Care Pathway lacks explicit considerations for mental health concerns, both during and post-pregnancy.
- The number of families needing access to early intervention services has risen in recent years and long delays in accessing early intervention services are prevalent. This is compounded by the effects of the Covid-19 pandemic and the limited number of human resources available.
- Chronic diseases, such as chronic kidney disease and diabetes, have a notable impact on maternal and child health within the current First 1,000 Days Integrated Care Pathway. While once regarded as products of adult behavior and lifestyle, these diseases are now being linked to processes and experiences occurring in pregnancy or infancy.
- Lastly, patient empowerment through information and respect throughout the care journey is not a priority in the current First 1,000 Days Integrated Care Pathway. Results from the Community Survey highlighted the difficulties women and their families face in accessing information that would support a better care experience. This includes care of premature babies, women’s’ inability to access antenatal information and pregnancy records, and the lack of insurance coverage for antenatal, breastfeeding, and birthing classes.
“Knowing the challenges that exist creates the opportunity to identify areas for improvement. Our work to date has identified 16 opportunities for improving the delivery of care and overall health outcomes for our pregnant mothers and their babies.
“While detailed information on the individual recommendations can be found within the final report, the opportunities for improvement focus on the following areas:
- enhancing collaboration and reaching consensus on care;
- establishing community engagement and enhancing information sharing;
- formalising the role of health visitors and fostering integration of mental health services;
- addressing barriers to care, while strengthening communication with off-island providers;
- offering support to women from the start and ensuring clear communication on what to expect;
- enhancing the midwifery role and focusing on the early years;
- establishing a link with oral health and organizing interdisciplinary care reviews; and
- enhancing support for families and empowering patients.
“The success of this work would not have been possible without the support and involvement of the working group members and the many stakeholders who were willing to share their experiences. I would like to express my appreciation for everyone involved in this work, particularly those with lived experience.
“This is not work that can be done in isolation. A holistic and collaborative approach is required if we are to address the barriers to care that currently exist and optimise the health outcomes of our children both now and over the course of their lives. And they are most definitely worth it!
“Thank you.”
Minister of Health Kim Wilson’s statement follows below:
“Good morning,
“Thank-you for joining us. This morning, Dr. Sylvanus Nawab and I will give an overview and share the results of the recently completed third integrated care pathway titled “First 1,000 Days.” This is part of Bermuda’s efforts to implement Universal Health Coverage.
“Recognising this, the Government prioritised this pathway in the 2022 Throne Speech, emphasising its importance for the Ministry of Health. Ensuring access to fulsome quality care from day 1 is foundational for a child to have the best chance at living a healthy life. Further, the 2023 Joint Strategic Needs Assessment, a study that set out to properly understand our population’s health needs, recommended a public health needs assessment on Child and Maternal Health, emphasising the importance of focusing on the First 1,000 Days Integrated Care Pathway.
“The Report that we are sharing today, presents the findings of the study that was conducted to assess and map the Island’s current First 1,000 Days Integrated Care Pathway. It incorporates maternal and child health, and adjacent services. Led by Dr. Nawab, who is Chief of Pediatrics at the Bermuda Hospitals Board and a Pediatrician with Edgewood Pediatrics, the multi-disciplinary working group overseeing this pathway included: Dr. Ricky Brathwaite – CEO of Bermuda Health Council, Tiara Carlington – Policy Analyst at Bermuda Health Council, and Dr. Attiya Talbot – Pediatric Officer at Department of Health.
“The objectives were to better understand current maternal and child health provision in Bermuda, assess user experiences, and identify existing challenges and opportunities. The work on this care pathway focused on five main lines of enquiry, including:
- service touchpoints, processes, and handovers of care between service providers;
- patient and family experience and what their care journey looks like;
- areas of overuse and/or duplication or redundancy of services and inefficiencies in their provision; and
- existing and perceived challenges in the delivery and access to services.
“As always, stakeholder engagement was a critical component of this work. 40 interviews were conducted with patients and their family members; clinicians, such as nurses, primary care providers, mental health care providers, and specialists; and operational professionals, such as those providing service coordination, family services and other relevant services.
“Three interactive stakeholder workshops were facilitated to capture the views and feedback of care providers involved in the current First 1,000 Days Integrated Care Pathway; and the Community Survey received 375 responses, the data of which was analysed according to age, household income, and the type of insurance held.
“The results were used to draft a Service Map for maternal and health services. A Service Map is a graphic depiction of the various components and interactions of a healthcare service, highlighting processes, stakeholders and touchpoints involved. It helps to identify areas of improvement and optimise service delivery.
“Patient personas were also developed to understand patient experiences in the Care Pathway and those experiences were plotted on the Service Map to create a Journey Map.
“The Journey Map breaks down patients’ experiences across different stages of the care service. It provides insights into patient perspectives, needs, and pain points, enabling healthcare providers to enhance patient satisfaction and outcomes.
“All of this work combined to highlight eight key findings, with ten challenges being identified, along with 16 opportunities for improving the current state of the First 1,000 Days Integrated Care Pathway.
“Dr. Nawab will now take you through those key findings and recommendations, after which I will discuss where we go from here, as we continue to work collaboratively to strengthen the First 1,000 Days Integrated Care Pathway in Bermuda.
“Over the past several months, you have increasingly heard me speak about the importance of, and the Government’s commitment to, implementing Universal Health Coverage and how collaboration amongst stakeholders is essential for successful implementation of priority recommendations.
“The First 1,000 Days Organisation tells us that “The 1,000 days from pregnancy to age two offer a crucial window of opportunity to create brighter, healthier futures. How well or how poorly mothers and children are cared for during this time has a profound impact on a child’s ability to grow, learn, and thrive.”
“There should be no question then, that ensuring our families have equitable access to needed, quality healthcare in the first 1,000 days of a child’s life, is a critical component in creating a foundation on which our youth can thrive as they move through their lives. And this needs to happen without creating a financial burden for families to receive that care.
“Together, we have the opportunity to enhance Bermuda’s First 1,000 Days Integrated Care Pathway, making it more accessible, affordable, navigable, and ultimately, improving health outcomes for our children.
“You have also heard me say that the ongoing work that is being undertaken to implement priority recommendations coming out of all the integrated care pathway initiatives will only be successful with the collaborative work of all stakeholders. This includes the Government, health service providers, insurers, people with lived experience, and residents.
“So let me echo Dr. Nawab’s expression of appreciation to the members of the First 1,000 Days Working Group and all stakeholders who came together in this work – especially the patients and families with lived experience. Your time and effort will have a positive impact and will guide the next phase of work.
“A Working Group for that next phase of work will be formed. Their work will include prioritising recommendations contained with the recently completed Report and then facilitating the implementation of the prioritised recommendations.
“To download the First 1,000 Days Patient Journey Map and Service Map, go to www.healthstrategy.bm/latestupdates.
“In the words of Seth Berkley, an American medical epidemiologist, “Healthy children are more likely to attend school and are better able to learn.” Let’s ensure all our children have the care they need to thrive from the start. It is our privilege to make this happen. Thank-you.”
The First 1000 Days Patient Journey Map follows below [PDF here]:
The First 1000 Days Service Map follows below [PDF here]:
