MCHB/EPI Miami Conference — December 7 - 9, 2005

Prenatal Care: Trials and Tribulations — Transcript

SUZANNE TOUGH: Thanks Sally. I almost feel like we should stop and talk about Katrina but maybe something that I'll talk about today will shed light on a conversation that we can all share afterwards. I'm delighted to be here to speak about a study that we carried out in Calgary, Alberta, Canada, which is the western part of the country and was the site of the 1998 Winter Olympics. I'm going to go through this study in the following order looking a bit at background and concluding with some public health implications.

This study came about maybe just by way of background; Calgary is a city of about one million population and about twelve thousand births per year. This study came about as a consequence of two committees that operated separately over a period of time. There was some sense that women were not accessing existing community resources throughout pregnancy and so post delivery were saying gee if only I'd known then I would have used whatever. Subsequent to that, there was some funding made available from the federal government to look at zero to six initiatives and what we were doing in early childhood. Some of this money was administered through health regions, through philanthropical organizations.

Calgary took the position that all service providers that work with children ages zero to six should come together and decide on some strategic priorities for allocation of the funds. So a working group was struck which met over a period of twelve months to address issues related to early childhood. The working group concluded that if we were going to tackle zero to six we should be starting at the prenatal period and that is when I became involved. They also thought that if they were going to introduce or try to understand prenatal care better they wanted to do what they considered gold standard work. So they didn't want a case control study, they didn't want program evaluation; they wanted a randomized control trial looking at how we should best deliver prenatal care to meet the needs of our population.

As we all know, prenatal care is an opportunity for health promotion. Our guidelines suggest ten to 14 visits over the course of pregnancy. And they also suggest that a holistic approach to pregnancy and health be included to address both psychosocial as well as medical needs. Now this great but in Calgary we have a shortage of service providers and delivery of medical care in and of itself requires a fair bit of time and attention. And so I think physicians are often asked to do nonmedical care that is above and beyond what they have the capacity to do in their clinic.

The key question we posed was does additional prenatal support from nurses and home visitors improve referral and access to appropriate resources for pregnant women living under a system of universal health care particularly those with complex or special needs. Three clinics participated. These were low risk maternity clinics in the city of Calgary , which were operated by about 30 physicians with associated staff. 2,556 women were invited to participate of which 68 percent agreed to participate at the beginning and you'll notice from the slide here we retained 78 percent through to the end of study. Women were randomized into one of three groups. The control group was the current standard of care which I mentioned before is ten to 14 visits over the course of pregnancy. Averaging in length about six minutes per visit. Another third of the women were randomized to a nurse intervention. This entailed programmatic intervention, individualized care throughout pregnancy delivered by a nurse in addition to the physician for medical care. The other third of the group was randomized to nurse and at home visitation. The nurses were trained public health nurses with more than 15 years experience. They were provided with additional training on the humanistic perspective of learning.

Competedency based approach to comprehensive pregnancy care. Solution focused therapy and solution focused approaches and in a community as partner model. The home visitors were pera professional home visitors that we recruited from our Calgary Immigrant Women's Association. So these were women that would have had maybe skills in a country that weren't recognized in Calgary and it was fortuitous that we were able to recruit an obstetrician trained from another country and a midwife trained in Holland . So our home visitors would have been considered pera professionals but they actually brought some expertise to the table already. They were provided with additional training and Invest In Kids and the Wisconsin model for Home Visitation and Within Our Reach.

So here is the population that we served. This actually is very representative of our current population in the city. The average age of women giving birth is 29 years. Fifty four percent have no previous children. Most had a partner. Seventy-five percent were Caucasian. More than 75 percent earned $40,000.00 or more per year and 73 percent had completed post secondary education. Just to reiterate this was a community based trial and so we weren't really anticipating any changes in birth outcome.

We were really interested in addressing women in a more holistic manner and you can see from the slide here that the babies were healthy. So how many visits did they have? What did they want? Women could direct themselves and could work with their provider, the nurse or the nurse and the home visitor to develop their own program of care through pregnancy in addition to their medical coverage. Fifty percent of the women had four or more visits with the nurse and the range was zero to eleven. The first visit took approximately 60 minutes and included completion of food frequency questionnaire in addition to other issues. But the food frequency questionnaire is interesting and I'll speak about that later.

Fifty-four percent of women who were randomized to the home visitor support had two or more visits. The range was zero to fourteen and they averaged about 75 minutes per visit. The bottom line was when we added in the increased support, we did have increase resource uptake among those groups of women. We had some more subtle findings too though. Women with the extra support received more information on prenatal vitamins and prenatal classes but three months post delivery were similar. Women with extra support received more information on early prenatal classes which are offered free of charge to the health region as soon as you are aware that you are pregnant and indeed rates of attendance were higher. As you can see from the other three rows we had extra information on parenting classes and rates of attendance were similar three months postpartum. We had extra information on nutrition and we were more likely to recruit women for nutrition counseling during pregnancy. Women had more information on breast-feeding but rates of use were similar. I should comment that breast-feeding rates on discharge from our hospital are about 86 and a half percent in the Calgary health region to date.

Some of the issues we were trying to work on were uptake of parenting classes. It has become a movement in our health region and unfortunately fewer than 25 percent of all parents avail themselves to parenting classes. Some of interesting findings were what were the favorite resources that women wanted to engage in and that they felt were informative and easy to use. They were written material and Early Start Helpline which is I guess the equivalent of a 1-800 number where you can phone and speak to a nurse about issues that you are finding through both pregnancy and early parenting. Prenatal class uptake was 49 percent among the whole cohort but it was 74 percent among women having their first infant. So what didn't happen? Well although women received more information on numerous topics, we didn't find or weren't able to achieve any overall differences in rates of reported abuse and neglect, use of a food bank or housing support. Smoking rates and alcohol consumption.

Postnatal depression, partner support post delivery or satisfaction with services. The last two bullets, partner support, post delivery was high and rated by more than 75 percent of the sample as very good or excellent. Over 85 percent of our group was satisfied with services. Our rates of abuse and neglect were under 20 percent but just as you had spoken earlier, we had fewer than 25 percent of our providers able to engage women in those conversations. So when you look at a population based approach like that. When you look at first pass of the data. Often you miss the subtle findings. It looks like you have very small effect which is part of the issues that we struggle with in public health but you take a step back and drill down into the data you can often find that there are pockets where the resources really made a tremendous difference.

I'll speak a little bit to that now. So 81 percent of women reported that they benefited from having the nurse and 43 percent indicated they really needed this service. As noted here 43 percent said they benefited from the home visitor and 22 percent indicated they needed the service. Traditionally in Alberta , home visitation is delivered through our ministry of Children's Services and I think some of the barriers we found with home visitation was this perception that it meant that you weren't doing something right already. The characteristics of women who are more likely to report that they needed the support are highlighted here and they include women having a first pregnancy and other characteristics that we would all probably find as common indicators of a high-risk psychosocial environment. Young maternal age, low income, non Caucasian, abuse, negative network orientation which reflexes to a reluctance to seek help or to seek support from others and women with low self esteem. So who needed the extra help? When we drilled down into the data it was the young women who were born outside of Canada or have lived in Canada for fewer than two years. Who lived with a lower annual income, had no previous children. Reported past periods of under employment, past history of sexual abuse, neglect or problems with alcohol use. Those who had never taken prenatal classes and those with psychosocial indicators as I highlighted before. We were able to identify that women attending one of the prenatal clinics in particular which is situated in a multi-cultural community in Calgary had more of these characteristics.

So the implications for service delivery are quite substantial. I think it was on the first one of the earlier slides where I highlighted that 74 percent of the sample is Caucasian. That does represent the demographics in Calgary and the other 25 percent are made of an immigrant population, multi-cultural immigrant population. Well how much did it cost because in order to move some of this work forward people always want to know if it does work, what is it going to cost me to put it into place. Standard care in the region so women just receiving the medical care. The cost was about $1,487.00 per mother. The additional cost of adding in the nurse was $90.00 a mother and the additional cost of the nurse and the home visitor was $170.00 a mother. So in conclusion we did find that support increased the information received and used for some resources.

We have key opportunities to identify and support those who would most need the additional support and those with risks characteristics report the greatest benefit and recognized that they did need the support. So we didn't have to do a huge amount to engage some of these women who actually benefited from the support. Our economic analysis suggests that the costs are acceptable particularly if allocated to high-risk women. One of the reasons the study was undertaken in the first place was because there was some incentive on the part of our community partners to provide all women in Calgary with additional support through pregnancy. I think we are able to demonstrate here that there is a good majority of women that actually are doing fine under our universal system of care and that if we strategically allocate resources we can maybe level the playing field a little bit.

I should mention about the economic analysis that I haven't highlighted here. When we look at a year post delivery how health services utilization differed amongst the groups. Well you know two things, one that women who had access to an intervention during pregnancy were less likely to seek care from a specialist in the year after delivery and were more likely to seek care from a family provider. So the costs probably wash out in the first 12 months post delivery. Another interesting finding is that some of these women that were high risk during pregnancy were screened post delivery as are all women in Calgary for additional support that might be required through the first year of life in terms of home visitation or extra support. Women that have the intervention during pregnancy required less home visitation support post delivery compared to women in the control group who might have had similar characteristics that didn't receive home visitation. One thing that we were hoping to do is normalize help seeking behavior through improved visibility of universal screening and improved uptake and access to existing community resources. I think that because our retention rates where high in the study, we do have some optimison that actually pregnancy is a time when we can engage women without it being associated with a stigma of things not going well or you're a high risk person so we will provide this for you and you are different from your next door neighbor.

The exciting part of this study that I think has really shaped the way I'll conduct my research is when the community asks for the work to be done they are eager to act on the results sometimes before you are even sure about what they say. Indeed there are efforts already under way in our health region to reorganize the way we deliver services and to try to meet the needs of the quadrant of the city that seems to be under served and seems to have benefited most from additional support. A study like this is done in partnership. I'm just the one here speaking to you about it today. As I mentioned there were thirty physicians that participated. There were numerous nurses. There was a steady staff. We had a cadre of interviewers who conducted women three times during the pregnancy to find out to address our academic needs and the partnerships are listed here. These are some of my team members identified more specifically. So thank you.

SUZANNE TOUGH: I prepared this not knowing how many people would stay or be shifting through topics. So now I'm going to tell you who we lost in this study. That is almost as interesting as who we kept. But I think I can move more quickly through some of the first slides. So this really, I'm going to talk to you now about what the implications are when women engage at the beginning of prenatal care but then we lose them part way through and how we can maybe structure our services to try and retain them and when we make planning decisions only based on who we retain, who we miss. Again, I'll follow the same format.

As I mentioned, prenatal care is publicly funded in Canada and is widely accepted as the standard of care. So in this analysis we were curious about whether or not sociodemographic characteristics, life style choices, psychosocial factors and life events differed between women who completed and women who did not complete a community based randomized control trial that provided of no charge supplementary prenatal care. As I mentioned before it was a prospective randomized control trial that enrolled all women attending the low risk maternity clinics in those three clinics in Calgary . They were randomized to one of the three interventions noted here. Overall we did find that those who engaged in the intervention had increased use of some pretty key community based resources.

We collected data three times over the pregnancy including one post partum interview. Then for this analysis we classified participants as either those who responded and completed all three questionnaires, those who dropped out so they withdrew from the program prior to completion of the third questionnaire or they became unreachable so we couldn't find them by telephone and I should really credit our interviewers here because way above and beyond the regular Dillman methodology we had 80, 90, 100 phone attempts for some of these women including our home visitors trying to track them down in the field. So from a total of 1,737 women who agreed to participate, 77.8 percent did complete the study. 10.2 percent dropped out and 5.3 percent became unreachable. One thing that is important when you are looking at this is did we lose women differently across groups. So were they more likely to stick with the medical care and just give up on the home visitation and indeed that wasn't what we saw. Noncompletion rates were similar across each group. So compared to those who responded, a significantly greater proportion of women who dropped out had characteristics that are noted as below.

Now we've asked about smoking and use of a food bank in the twelve months prior to pregnancy. Compared to those that responded, a significantly greater proportion of women who became unreachable had the following characteristics as noted below. Young maternal age, single, low income. You'll notice that they are similar to the previous slide. This includes women who became unreachable were slightly more likely to have substance abuse issues. The common characteristics are noted here. They were young, low income, low education, smokers, had reported use of the food bank in the twelve months prior to pregnancy and had some psychosocial characteristics that would make them at risk of feeling isolated or alone in our community.

When we did logistic regression to find out about the key predictors of women who dropped out, these are noted here. The women of non Caucasian ethnicity with less than a high school education, came from a family where parents were separated or divorced and had reported low social support or scored low on our standardized social support scale. Those who became unreachable had the following characteristics. They were young, again less likely to have completed high school, more likely to be single, to have low income and to report smoking. Among those who stayed in the study, the characteristics of women who reported the greatest need and benefit from the intervention had most of the characteristics that reflect those that we were unable to retain in the study with the exception of first parity. So in conclusion I think that we have missed opportunities to engage women with the most complex needs in our prenatal care programs despite the fact that we were able to demonstrate that they benefited most from being availed of the additional service. We still had more problems retaining them. I think if women can be engaged in the system, there are opportunities to improve both resource utilization and informational support, which can potentially improve birth outcomes. I think there are some other implications that I would like to talk about here though.

One of the issues I think we face and I should mention that all of our nurses and home visitors could speak more than one language so women could get the service in their own language. But I think that we are often reluctant to go to places where we feel uncomfortable ourselves with our clients and so issues like past history of sexual or physical abuse, home insecurity, low social support make us feel uncomfortable as though delivering the intervention. And yet those are the kind of conversations I think we need to have with these women in order to retain and to meet them where they are at instead of asking them to meet us where we are at. I think some of the things that I'm looking forward to trying in our health region is to encourage and support providers in getting the skills that may improve their ability to engage and retain these women in care. Also to try some different service delivery models that might seem more user friendly for women such as extended office hours, group prenatal care and you have an excellent program for the states called Centering Pregnancy that we are looking forward to pilot testing and easy to access venues. I think that we know enough about how the brain works to know that if you see something frequently for short periods of time you trust it more than something you see infrequently for the same number of minutes. So if we were to put our services in places like Wal-Mart or our local low cost grocery stores then I think you can begin to build a trust with these clients that might make not only it more accessible for them but might make use of services better.

So again my partners and again those that worked with in more detail. I've gone over it quite quickly because I am aware it is the last session on Friday and it is a beautiful day and all that so I've probably skipped a few things and I'm happy to discuss them. Thank you.