1. DECISION SUPPORT RESEARCH TEAM “Providing expertise to improve health & wellbeing of families” Retention in a Study of Prenatal Care: Implications of attrition for program planning Suzanne Tough, PhD 11th Annual Maternal and Child Health Epidemiology Conference Miami, Florida December 2005

2. Background Study Question Methods Results Conclusions Public Health Implications Community Perinatal Care Study

3. 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)

4. 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?

5. 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 + Nurse 3. control + Nurse + Home Visitor

6. 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

7. 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

8. Methods CPC participants were classified as: 1. RESPONDER (completed all 3 questionnaires) 2. DROP-OUT (withdrew from program prior to completion of the 3 rd questionnaire) 3. UNREACHABLE (could not be contacted by telephone at some point after the initial questionnaire) CLASSIFICATION

9. 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)

10. 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

11. Results Summary COMPARED 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

12. 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

13. Logistic Regression Results The key predictors of women who dropped out of the study included: CharacteristicOdds Ratio95% C.I. non-Caucasian ethnicity1.55(1.11, 2.19) < high school education1.86(1.17, 2.95) parents separated or divorced 1.47(1.06, 2.04) low social support1.43(1.05, 1.97)

14. Logistic Regression Results The key predictors of women who became unreachable during the study included: CharacteristicOdds Ratio95% C.I. maternal age < 25 years2.17(1.33, 3.52) < high school education2.60(1.40, 4.83) single1.89(1.09, 3.28) < $20,000 annual income2.04(1.28, 3.24) smoker1.86(1.17, 2.93)

15. 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:

16. 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

17. 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)

18. Who We Worked With Calgary Children’s Initiative Calgary Immigrant Women’s Association University of Calgary Pediatrics Community Health Sciences CHAPS Low Risk Prenatal Clinics (NE/NW) Calgary Home Visitation Collaborative Calgary Health Region Decision Support Research Team Healthy Communities Health Survey and Evaluation Unit Physician Partnership Steering Committee

19. The CPC Study Team