Healthy start in life

Giving children a healthy start in life must be a top priority for any society. This subchapter focuses on creating health for infants and young children up to school age. It includes life events such as birth;

physical development; learning to walk and speak; acquiring basic social and health values; discovering the environment; and strengthening bonds to parents and people close to the family.

The chances of a child being born healthy are unequal throughout the Region, and this is also true of the chances of a child surviving its first year of life. Most western European countries have, at national level over the past fifteen years, met the regional HFA target of reduced infant mortality, but even in the richest countries there are significant inequalities between social groups. The high infant mortality rates in some countries in the eastern part of the Region give rise to particular concern. An unwelcome pregnancy is a risk factor, and the considerable number of teenage pregnancies, for instance, is an important problem in many countries. Abortion is still used as a major means of contraception in some countries – a practice that is unacceptable at the turn of the century.

A healthy birth establishes the basis for a healthy life, and pre- and perinatal services may contribute significantly to helping mothers and infants cope with this crucial life event. Pregnancy and delivery are natural physiological processes – although at times they go wrong – and should be regarded as such by health professionals. The better a mother’s state of education, health and nutrition, and the higher her socioeconomic living standard and the quality of health-related services she receives, the greater is the chance of a successful pregnancy.

There is considerable inequity in the provision and quality of perinatal and postnatal services in the Region. Whereas some countries spend large amounts of money on increasing the life expectancy of very low birth-weight infants, the basic requirement of ensuring a healthy birth is not met in large parts of the Region. The very success of perinatal medicine in ensuring survival at ever lower birth weights has been associated with a greater number of children being born with special needs, raising important ethical questions.

Birth weight, which is related to income (but also to other factors, such as smoking), is a marker for indices of deprivation and represents accumulated risk over generations. Even when compared with others in the same social class, a child’s reduced birth weight is associated with a greater risk of physical ill health, including death from coronary heart disease and psychological ill health in adult life. Birth weight is also related to subsequent social circumstances in childhood and up to early adulthood, including adult occupational social class. The first year of life is crucial for healthy physical and mental development and for health later in life, and children born into disadvantaged home and family

circumstances are at higher risk of poor growth and development.

Strengthening bonds to parents and people close to the family: Parents and other close people have an important role to play in conveying basic health and social values to children of this age group. In times of crisis or difficulty, or situations where there may only be one parent, parents and those taking care of

children do not always have the necessary parenting skills or support. Europe faces important changes in family structures. The number of “traditional families” is decreasing, as a result of higher rates of family breakdowns and increases in the proportion of births to unmarried mothers. Divorce rates have risen markedly in CCEE, with especially significant increases in the Russian Federation, Belarus, the Republic of Moldova, Slovakia and Estonia. Children can suffer if families split up. The pressures are greater on families in some parts of western Europe, where traditional social support networks are deteriorating, than in southern and eastern parts of the Region, where they are still strong.

Infant and child abuse has lasting and traumatic effects on the individual’s mental health. The number of marginalized street children is increasing in the Region, and the problem does not always receive as much attention as it should. Children from immigrant families, refugee families, families staying illegally in foreign countries and homeless families are most at risk of becoming street children and hence of delinquency, prostitution, truancy, drug use, poverty, violence and begging.

TARGET 3. HEALTHY START IN LIFE

BY THE YEAR 2020, ALL NEW BORN BABIES, INFANTS AND PRE-SCHOOL CHILDREN IN THE REGION SHOULD HAVE BETTER HEALTH, ENSURING A HEALTHY START IN LIFE.

In particular:

3.1 all Member States should ensure improvements in access to appropriate reproductive health, antenatal, perinatal and child health services;

3.2 the infant mortality rate should not exceed 20 per 1000 live births in any country; countries with rates currently below 20 per 1000 should strive to reach 10 or below;

3.3 countries with rates currently below 10 per 1000 should increase the proportion of new born babies free from congenital disease or disability;

3.4 mortality and disability from accidents and violence in under 5 year-olds should be reduced by at least 50%;

3.5 the proportion of children born weighing less than 2500 g should be reduced by at least 20%, and the differences between countries should be significantly reduced.

Proposed strategies

The question of how to deal with the underlying social and economic determinants, in order to decrease infant mortality within and among Member States, is discussed in Chapter 5. To ensure that pregnancies are wanted and carried through in the best possible condition, it is important to have a good family planning programme for the population (including genetic counselling, when appropriate). For pregnant women, essential services include basic medical check-ups and good help for parents-to-be with stopping smoking, guidance on nutrition, and psychological and physical advice on pregnancy, delivery and child care.

A healthy birth should be assisted by well trained midwives, with back-up services from obstetricians only in case of need. Pre- and perinatal care should rely on evidence-based essential technologies only, with more sophisticated technology reserved for special, clearly identified needs; potential iatrogenic side effects should always be kept in mind. Separating mothers and infants at birth, and putting too much emphasis on regularity, discipline and hygiene, all interfere with protective physiological mechanisms and should therefore be avoided; in this context, the WHO criteria for baby-friendly hospitals (see below) are a useful source of advice. Future mothers, fathers and other family members should refrain from smoking, and the mother should avoid the use of drugs and alcohol. Good and timely immunization coverage is a basic disease prevention mechanism and should always be ensured (details can be found in Chapter 4).

Breastfeeding provides optimal nutrition, creates strong bonds between mothers and children, reinforces the immune system and gives additional protection against infectious diseases and allergies during

childhood. Almost every mother has the capacity to produce milk which exactly meets all the nutritional requirements of her particular baby for about six months. This is true even under the conditions

generating severe and long-lasting physiological and psychological stress which are currently found in many countries in the Region.

THE BABY-FRIENDLY HOSPITAL INITIATIVE (BFHI) was launched by WHO and UNICEF in 1991 at a meeting of the International Paediatric Association in Ankara, with the following objectives:

• to enable mothers to make an informed choice about how to feed their newborn babies;

• to support early initiation of breastfeeding;

• to promote exclusive breastfeeding for the first six months;

• to ensure cessation of the free and low-cost supply of infant formula to hospitals;

• to include, possibly at a later stage and where needed, other mother and infant health care issues.

This global network aims to give every baby the best start in life by creating a health care environment where breastfeeding is the norm, thus helping to reduce the levels of infant morbidity and mortality in each country.

In the European Region of WHO, as at March 1996, there were 191 baby-friendly hospitals in 11 countries but the aim is include all hospitals in the Region.

A safe, stable and supportive home environment is of particular importance for infants and young children, since they spend a lot of time in and near the home and are particularly vulnerable to the health hazards found there: communicable diseases; water-, food- and animal-borne infections; diseases caused by poor sanitary conditions; chemical hazards from air, water, and soil pollution; and physical hazards in the home, neighbourhood and traffic. Creating an environment which allows children to develop their physical, emotional and social potential is an investment with long-term health effects. This environment should be smoke-free, since passive smoking has a clear detrimental effect on children’s health. Social policies should give support to families in need, allowing them to create a nurturing, stable and safe home environment.

A family nurse making home visits can be highly instrumental in helping parents create a healthy,

psychosocially stimulating and active environment for the infant, as well as one which prevents injuries at home.

The private sector can contribute to health, for example by manufacturing healthy toys which enhance children’s imagination and development.

Acquiring basic values: In the first seven years of life, stable social relationships are known to contribute significantly to a person’s psychological make-up and the ability to cope with stressful events throughout life. The experience of profound and loving human relationships builds a strong health resource for the whole life course. Parenting education for mothers and fathers could be part of health services.

Establishing partner and family counselling, as well as school education programmes in group dynamics and conflict solving, may have positive health effects in the case of parents separating.

The kindergarten and similar child care facilities are excellent settings in which to convey basic health values and develop social skills, and where equity, solidarity and human dignity, for example, can be experienced and taught. Such facilities can also contribute to the healthy development of young children by providing a model of a healthy physical and social environment; by encouraging children to prepare healthy food together; by teaching them “life skills” of social interaction; and by supporting and

introducing basic hygienic behaviour. Countries need to make much greater efforts to ensure that all such institutions have systematic programmes to meet these requirements, including staff trained for the purpose.

Supporting vulnerable and at-risk children, especially those who may not already be within the social welfare system, requires effective community and outreach services. Working together with other

partners, including the social sector, children’s welfare services, NGOs and charities can make for more effective action. A very important, but difficult task is to develop programmes in all Member States to prevent infant and child abuse, and to rehabilitate children who have suffered abuse. This requires a new openness in many societies to talk about problems which hitherto have been “swept under the carpet”.

WHO GUIDELINES ON "INTEGRATED MANAGED CARE OF THE SICK CHILD"

The guidelines aim to reduce mortality and the frequency and severity of illness and disability in countries, and to contribute to better growth and development. The interventions focus on the quality of the care provided by outpatient health facilities and at community level.

The initiative is considered to have the potential to make a large impact on the global burden of disease and to be extremely cost-effective. It is based on three components:

• improving the case management practices of health staff, by providing guidelines on the integrated management of childhood illness adapted to the local context and by organizing activities to promote their use;

• improving the health infrastructure required for effective management of childhood illness, including the supply and management of essential drugs and vaccines and supervisory capabilities at national and district levels;

• improving family and community practices.