Lots of organizations that support parents with multiple births were cited.
Recognize that home support is critical for breastfeeding success, therefore lactation consultants were recommended.
Parents should discuss breastfeeding concerns and strategies - provide tips.

Suggestions for addressing gaps:

Look into insurance (private) coverage prenatally.
Start taking prenatal classes earlier than expectant mothers of singles.
Have "guest" parent talk about the challenges and need to support.
Mom's talk dads through latching on.

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Groups offered a number of interesting ideas for explaining the experience of birth including an egg in water, or play dough to describe cervix dilation.
Having a toy box filled with things like highlighters, squishy balls and pipe cleaners might appeal to fathers who typically like to keep their hands busy during class.
The need to be sensitive to various family dynamics when facilitating was also expressed (couples, single women with mom or sister, lesbian couples etc.). This includes having activities that will work with these various dynamics.
It was felt that one way to ensure teens continue to come to the program is to give them some sense of ownership (i.e. deciding what food for the next week) and ensuring there are a variety of activities such as Knapsacks to demonstrate weight gain in pregnancy.
Several references to books or other resources included "Idea Box" by Terry Schilling, "Innovative Teaching Strategies" by Connie Livingstone, and the Toronto Public Health, CPNP Facilitator's Guide.
As with other groups, the suggestion for an online website or listserv was suggested, as a place to share ideas.
The idea of an annual conference for prenatal educators that travels to 3 or 4 areas of Ontario was suggested. This would provide the kind of face to face interaction that was felt to be needed.

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Suggestions made regarding existing programs & resources:

Because there are many factors contributing to risk, there were many suggestions about what needed to be considered. There seems to be no set age limit, and it was felt there should be no cut off age (anything from 15 - 45).

Drop-in youth programs seemed to work well for teens, but for others it was felt a one-on-one prenatal class might work well.
Offer "community prenatal" for high risk clients that can't come to classes, and use snacks and bus vouchers to encourage attendance. (Offering food is another recurring theme)
Some centres offer 8 weeks postpartum and then link to other community resources, and other centers offer a series of classes for groups such as the Mennonites, at Women's college hospital, out of shelters, high schools and at detention centres. (ranges from 4 - 8 weeks of classes)
CPNP funded programs mentioned several times in various locations (St. Thomas, Healthy Start programs, St. Catharines etc.) PHN and CAS workers may attend and help to set a positive tone (PHN does postpartum visits for high-risk clients in London).
Suggested incorporating information for multiples in prenatal classes. Other medical concerns might then be raised.
In some cases women drop out because of medical problems and they may then receive home visit. It was felt there might be a gap here and the question was raised as to who follows up when they are on bed rest at home.

Addressing Gaps:

Include everyone (youth - 40) in one class.
Flexibility of drop in program important.
Programs ranged from 6 weeks to 8 weeks and various options for delivering were suggested. In some cases classes ran over consecutive weeks, while in others there was a 4 week break between the classes, offering the final classes closer to due dates.
Selected PHNs to provide one-on-one service to under-housed, homeless or sheltered women, acting as liaison with shelters. Need to address gaps for refugees, language barriers, poverty, homeless, food security, and disabled women.

Other Ideas:

On-line prenatal classes and chat rooms suggested.
Also looking to Best Start for a list or inventory of available resources, funding sources and who funds what.

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Many groups other than this one suggested online delivery of prenatal education.

It was suggested there was a lot of online material out there, but no official "class", and not always accurate. Wants to expand material offered.
Felt that many teens access information online regularly. Considering restructuring classes to adapt to online format, or a blended program (online and in-class learning).
Ensure it is not a "read only" site.
One of the challenges with the electronic learning field is the fact it is constantly changing. Face to face interaction is still important, so blended model is attractive.
Grey Bruce Public Health does have an online program.
Concerns raised about non-credible internet sites and the fact that as nurses we lack the skills to make an interesting website attractive to others.
Best to address this at the provincial level (i.e. Best Start) to ensure everyone isn't reinventing the wheel by developing curriculum at each health unit.

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Suggestions made regarding existing programs

No specific cut off regarding number of weeks in pregnancy that you can attend.
In some cases the Health Units are getting individuals later in pregnancy, so they are piloting a 2 hour preconception/prenatal class and are distributing prenatal resource packages (Elgin/St. Thomas HU).
Some centres focus on young moms and others recruit door to door in a housing project (Brantford). Others distribute packages via family doctors and midwives.
Perth District HU - Offers series of 3 early classes, preconception/prenatal health fairs, prenatal packages for distribution via family doctors/midwives
Peel Region: HBHC staff at existing prenatal programs to introduce/enhance uptake of HBHC program prenatally.
Also suggested programs for dads on smoking or substance abuse.
Felt Best Start could develop a comprehensive "early prenatal curriculum" or a provincially led campaign.
Suggested sharing PowerPoint presentations that have already been developed.
Resources referred to include "The Healthy Journey: Your contemporary guide to pregnancy" "Superior Dads", and other "dad's" resources.
Group is interested in sharing resources and connecting with each other.

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Dads only sessions suggested.
Saturday sessions have been successful.
Some are finding a decline in attendance throughout the series. Need to address this problem. Some recommended consecutive classes and enforced program cut-offs.
Would like to explore if there is a different participation rate with non-nurse program registration and what aspects of prenatal education are best accomplished in groups and what could be delivered on-line or independently.
The role of food in the programs was raised.

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Emphasized the importance of being flexible and addressing the needs of the local community.
Partnerships with grassroots community development agencies for newcomers and with other health care professionals. Need to be culturally sensitive.
Need reciprocal relationship between Public Health and CHC's / hospital classes
Also need more assessment at the client level and the development of on-line/electronic resources. Post-natal evaluation of prenatal strategies.
DVD class content that could be adapted to meet need.

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For teens, the flexibility of a drop-in program format works well.
Group interventions can be challenging when participants need one-on-one attention.
In some cases the program has shifted to include both group and individual programs, based on the needs of the client base.
Topics need to be kept short, and location is important (mall space works well in Toronto).
Maintaining partnerships also challenging because of differences in approach, style and philosophies.
Need to address concerns in how CPNP partners are included to ensure issues of cultural barriers and safety concerns are dealt with.
Other ideas to consider included training of new facilitators by Best Start, and communication of existing resources.

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Discussed the increase of pregnancy in women over 35 and the increased risks, including preemies. For many, it may be a second marriage and the start of a new family.
Innovative strategies included exploring lifestyle issues for this group (high expectations, sleeping issues, lack of family resources, sibling rivalry if 2nd marriage, no concept of reality etc.).
Increased risk of depression and possibility of resentment.
Clients often more willing to challenge knowledge sources (Type A personalities).
Possibility of a web link was again surfaced.
Need to facilitate research initiatives regarding the identification of high risk criteria. Need workplace risk identification.
Best Start has made good contributions in terms of resources.

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In considering why recruiting and retaining is so difficult, the group looked at issues such as transportation, the possibility future parents don't see the need, time commitments and reluctance of teens to come alone.
Some centres have tried to offer classes at a variety of times and in a variety of venues, and collaborating with other agencies (such as the guidance counsellors in high schools and HBHC) Word of mouth seems key to success of the program.
Suggestions for addressing the gaps included more social marketing campaigns (perhaps a display in the malls) and using online websites and resources. Need to think outside the traditional prenatal classes
Invest in kids tracked where people found out about program (had hard time recruiting). Found out media and public health departments were the most useful.
Maintaining a blend of face to face and web resources may help meet everyone's needs.
Other ideas included using Pod-casts or You-Tube to put classes on line.
Use tear off posters and automated reminder calls.
Expect drop outs and overbook the class to account for this.
Provide childcare (team up with EYC)é
Make classes "pick and choose", so they can attend what they feel they need, and offer weekend classes as an option.
Agencies should not to work in silos (sexual health team, HBHC, reproduction) - should collaborate. One participant had started a coalition - community partnership.
Example of "Just in time" for late prenatal registrants; 2 - 3 hour session with a facilitator, what you need to now (Durham Health Unit)
Might also ask for deposit to combat perception that there is no value in the education.
Do reminder phone calls (through automated system)
Popular suggestion of offering food & perhaps draws.

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Offering informal sessions and drop-in programs seems to be successful.
Peer mentoring and social contacts beyond the group were seen to enrich lives and provide more access to parenting information (i.e. discipline etc.).
The assumption is that moms know what to do, but it appears they can be ill-equipped for parenthood.
Support systems and exposure to lots of ideas and suggestions is helpful.
Following up at home also helpful, but internal structure of delivering services by Public Health nurse can be difficult.
It would be helpful for parents to have access to a computer although concerned that some information online isn't accurate and may be misleading.
Again the idea of more "fathers only" groups was surfaced.

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The idea of a postnatal reunion was felt to offer opportunity for follow-up and for evaluating the impact of the programs. Should consider barriers to attending.
Follow up with clients who stop attending to determine reason would be useful.
Completing evaluation after 1st session also suggested. May want to offer incentive for completing evaluation.
Also suggested asking for evaluation when post-partum ICQ is completed at the CPNP.
Other suggestions: THCU (The Health Communication Unit), list of resource from presentation by Simcoe-Muskoka, Epidemiologist, students.
Suggested Best Start would develop a framework for completion of evaluations.

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Involve community partners right from the start.
Offer displays: handouts, labour & delivery information, ultrasound, hands on interactive booths, education regarding safety (car seats, 3D's)
Offer mini fairs for rural regions
Link up with other fairs (children & Prenatal)
Have policies for exhibitors (profit vs. non-profit)
Advertise & have financial backing (marketing)
Be aware of other activities happening at same time
Ensure easy access to facilities (affordability, parking etc.)
Be aware of time of events (crucial) suggesting 5 - 8 p.m.
Avoid draws taking place in booths as your exhibitors become marketers
Bring in speakers (professionals and parents who have experience)
Provide food for those participating in the fair
Provide prizes & fun areas. Exhibitors may donate door prizes - listed in advertisement
Building in working workshop when developing fair events
"Tried and true" video - comfort measures in labour
Have a welcome wagon to deal with issues etc.

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