DECISION SUPPORT RESEARCH TEAM

“Providing expertise to improve health & wellbeing of families”

Retention in a Study ofPrenatal Care:

Implications of attrition forprogram planning

Suzanne Tough, PhD

11th Annual Maternal and Child Health Epidemiology ConferenceMiami, FloridaDecember 2005

• Background • Study Question• Methods• Results• Conclusions• Public Health Implications

Community Perinatal Care Study

Background

• Prenatal care is publicly funded in Canada and widely accepted as the standard of care for pregnant women

• Prenatal care provides an opportunity to address medical and psychosocial concerns that impact health

• Challenges exist with retaining high-risk women in prenatal care (i.e. young, low income, non-Caucasian)

Study Question

Did socio-demographic characteristics, lifestyle choices, psychosocial factors, and life events differ between women who completed and women who did not complete a community-

based randomized controlled trial of supplementary prenatal care?

Community Perinatal Care (CPC) Study

BASICS prospective randomized controlled trial

pregnant women attending low risk maternity clinics in Calgary, Alberta were recruited prior to first prenatal appointment

study groups:1. control (standard of care at prenatal

clinic)2. control + Nurse3. control + Nurse + Home Visitor

Just to let you know…

• Overall CPC results indicated that women who had the intervention increased their use of pregnancy-related resources

Early prenatal class Parenting classes Nutrition counseling Written material Agencies who provide lists of child care facilities

Methods

• 3 telephone questionnaires first trimester mid-pregnancy 6-8 weeks post-partum

• Questionnaires gathered information on: demographics obstetrical history lifestyle choices psychological functioning social support and network orientation life events

DATA COLLECTION

Methods

• CPC participants were classified as:

1. RESPONDER (completed all 3 questionnaires)

2. DROP-OUT (withdrew from program prior to completion of the 3rd

questionnaire)

3. UNREACHABLE (could not be contacted by telephone at some

point after

the initial questionnaire)

CLASSIFICATION

Recruitment and Retention Rates

From a total of 1737 women who agreed to participate:

1352 / 1737 = 77.8% completed the study

177 / 1737 = 10.2% dropped out

92 / 1737 = 5.3% became unreachable

NOTE: Non-completion rates were the same across intervention groups

(*There were also 116 / 1737 = 6.7% who did not complete the study for other reasons, such as miscarriage)

Results Summary

COMPARED TO RESPONDERS:• A significantly greater proportion of women who dropped

out of the study had characteristics that included: young maternal age (<25 years) non-Caucasian ethnicity low income (<$40,000 / year) low education (< high school) daily smoker* use of food bank* low social support negative network orientation history of depression came from a family with separated / divorced parents

*during 12 months prior to pregnancy

Results SummaryCOMPARED TO RESPONDERS:• A significantly greater proportion of women who became

unreachable had characteristics that included: young maternal age (<25 years) single low income (<$40,000 / year) low education (< high school) daily smoker*, use of street drugs*, and/or use of food bank* low social support negative network orientation history of alcohol, drug, unemployment, suicidal thoughts/attempts

or depression problems came from a family with separated / divorced parents

*during 12 months prior to pregnancy

Common Characteristics

young maternal age (<25 years) low income (<$40,000 / year) low education (< high school) daily smoker* use of food bank* low social support negative network orientation history of depression came from a family with separated / divorced parents

*during 12 months prior to pregnancy

Logistic Regression Results

• The key predictors of women who dropped out of the study included:

Characteristic Odds Ratio 95% C.I.

non-Caucasian ethnicity 1.55 (1.11, 2.19)

< high school education 1.86 (1.17, 2.95)

parents separated or divorced

1.47 (1.06, 2.04)

low social support 1.43 (1.05, 1.97)

Logistic Regression Results

• The key predictors of women who became unreachable during the study included:

Characteristic Odds Ratio 95% C.I.

maternal age < 25 years 2.17 (1.33, 3.52)

< high school education 2.60 (1.40, 4.83)

single 1.89 (1.09, 3.28)

< $20,000 annual income 2.04 (1.28, 3.24)

smoker 1.86 (1.17, 2.93)

Subtle CPC Findings

Characteristics of women who reported need of additional support:

First parity Low income Non-Caucasian Abuse during pregnancy Young maternal age Lower network orientation Low self-esteem

AMONG THOSE WHO STAYED IN THE STUDY:

Conclusions

• There are missed opportunities to engage women with the most complex needs in prenatal care programs

• If women can be engaged in the ‘system’, there are opportunities to improve resource utilization and informational support, potentially improving the birth experience

Public Health Implications

• Healthcare providers may wish to improve their ability to engage and retain high risk women

• Programs designed to engage and retain high risk women should consider different delivery models that facilitate access and use of services extended office hours, group prenatal care, easy to

access venues (i.e. grocery stores)

Who We Worked With

Calgary Children’s Initiative

Calgary Immigrant Women’s Association

University of CalgaryPediatrics

Community Health SciencesCHAPS

Low Risk Prenatal Clinics (NE/NW)

Calgary Home Visitation Collaborative

Calgary Health RegionDecision Support Research Team

Healthy CommunitiesHealth Survey and Evaluation Unit

Physician Partnership Steering Committee

The CPC Study TeamInvestigators and Partners

Dr. Suzanne Tough (Principal Investigator), Departments of Pediatrics and Community Health Sciences, Faculty of Medicine, University of Calgary; Decision Support Research Team, Calgary Health Region

Dr. Carolyn Lane, Low Risk Maternity Clinic Dr. Gayleen Jorgensen, Maternity Care Clinic Dr. Linda Slocombe, Grace Maternal Child Clinic Corine Frick, Director, Alberta Perinatal Health Program Laurie Blahitka, Director, Women’s Health, Calgary Health

Region Suzette Miller, Manager, Grace Women's Health Centre,

Calgary Health Region Varina Russell and Donna McLeod, Directors, The Calgary

Children's Initiative, United Way of Calgary and Area Dariel Bateman, Project Manager, The Calgary Children's

Initiative, United Way of Calgary and Area Anila Ramaliu, Coordinator, Healthy Communities, Calgary

Health Region Stephanie Won, The Calgary Children's Initiative, United Way

of Calgary and Area Toni MacDonald, Director, Children's Inpatient and Outpatient

Programs, Calgary Health Region Edna Sutherland, Calgary Immigrant Women's Association Hamda Umar, Coordinator, Cross Cultural Parenting Program,

Calgary Immigrant Women's Association Alan Shiell, Professor, Centre for Health and Policy Studies and

Department of Community Health Sciences, Faculty of Medicine, University of Calgary

Marjon Van Der Pol, Assistant Professor, Department of Community Health Sciences, Faculty of Medicine, University of Calgary

Flora Au, Research Assistant, Centre for Health and Policy Studies, Faculty of Medicine, University of Calgary

Brenda Fischer, Executive Director, Child and Women's Health Portfolio, Alberta Children's Hospital, Calgary Health Region

Brent Scott, Professor and Head, Department of Pediatrics, Faculty of Medicine, University of Calgary

Council of Champions, The Calgary Children's Initiative, United Way of Calgary and Area

Conception to Age 5 Working Group, The Calgary Children's Initiative, United Way of Calgary and Area

Study and Clinic Staff

David Johnston, Study Coordinator, Decision Support Research Team, Calgary Health Region

Jodi Siever, Biostatistician, Decision Support Research Team, Calgary Health Region

Monica Jack and Michelle Wu, Analysts, Decision Support Research Team, Calgary Health Region

Roberta Hunt, Study Nurse, Calgary Health Region Shahin Kassam, Study Nurse, Calgary Health Region Ranjit Uppal, Study Nurse, Calgary Health Region Leanne Vroegryk and Jyotti Sandhu, Study Visitation

Team, Canadian Immigrant Women's Association Low Risk Maternity Clinic, Grace Maternal Child Clinic,

and Maternity Care Clinic Laurie Kennedy and Doris Sylvain, Research Assistants,

Calgary Health Region Tim Cooke and Mona Sletten, Health Survey and

Evaluation, Calgary Health Region Mary Burcher, Joslyn LaBrash, Daniela Wolff, Anita

Jonsson, Betsy Nelson, Kanwal Arora, Huda Nasser,