# Presentation: 564262

## A Randomized Controlled Trial of Supplementary Prenatal Care: Implications for Service DeliverySuzanne Tough, PhD11th Annual Maternal and Child Health Epidemiology ConferenceMiami, FloridaDecember 2005

**A Randomized Controlled Trial of ****Supplementary Prenatal Care:**** ****Implications for Service Delivery****Suzanne Tough, PhD****11****th**** Annual Maternal and Child Health Epidemiology Conference****Miami, Florida**December 2005

## Community Perinatal Care (CPC) Study 

- Background
- Key Question
- Methods
- Results
- Conclusions
- Public Health Implications

## How we started

- Working Group on Post Partum Services of the Maternal-Newborn Committee, Calgary Health Region (1997) had identified that women lacked awareness of existing prenatal community resources
- A Working Group of the Calgary Children’s Initiative (United Way) (1999/2000) identified role of prenatal care in improving pregnancy experiences and birth outcomes

**Notes:**
Approximately 12,000 infants are born annually in Calgary.  Despite the availability of many services, families in the Calgary region have stated that their maternity-related care could have been improved by knowing about community resources earlier in pregnancy (Program design 1997 ref report). The Maternal-Newborn Program Design Committee Calgary Health Region (CHR) report recommended the design and implementation of an integrated service delivery system that would be more responsive to consumer needs and better co-ordinated among service providers and agencies. The report also recommended redesign of the role of the community health nurse in prenatal care to complement and augment the practice of community based family physicians. Concurrently, community organizations brought together by the Calgary Children’s Initiative (United Way) were invited to provide direction in order to address health and wellness outcomes for Calgary’s children, including defining the outcome that “all children would have a positive start in life.” This study was consequently designed to address the concerns of the Calgary Children’s Initiative, and recommendations from the of the Calgary Health Region (CHR) related to appropriate, timely and universal access to prenatal resources.

## Significance

- Prenatal care is an opportunity for health promotion
- Most women in Canada have 10-14 visits
- A holistic view of health includes addressing psychosocial as well as medical needs
- Low medical risk maternity clinics are at capacity

**Notes:**
Preantal care is cornerstone of health promotion for pregnant women. Typically it is initiated in the first trimester of pregnancy and has an increased schedule of visits as the pregnancy progresses, typically 10-14 visits for a term pregnancy. (SOGC guidelines) 93.1% of women have more than 4 prenatal visits, and are in contact with health professionals during this period, (MRF Tough, tofflemire), there is an opportunity to assess and intervene to modify lifestyle behaviours which may increase the risk of poor birth and infant outcomes, such as tobacco use, alcohol consumption, and food/ housing insecurity (ref).  Early and regular prenatal care is advised to allow for screening, identification of risk, education and provision of specialized care where needed.(SOGC guidelines) However, although publicly funded health care is available to all women, those most in need of care, such as teenagers, unmarried women, smokers may seek care later in pregnancy, and have fewer visits.  (mrf 1 tough) 
Limited visits and late care may impede the capacity of physicians to address non medical needs, including the social determinants of health such as social support, employment, personal health practices and coping skills which have been identified as having substantial influences on health (ref Ottawa Charter and Taking action on population health). Furthermore, women marginalized as a result of poverty, language barriers, or youth may have extra ordinary needs which could be met through improved access to existing community resources, such as food banks, prenatal services for young mothers, or prenatal programs in languages other than english.

## Key Question

- 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?

## CPC Methods

**Groups**

**# of women****at CPC 1**

**# of women****at CPC 3**

**Completion****rate**

**All Groups**

**1737**

**1352**

**68% response rate**

## CPC Program

- Nurse
- Humanist Perspective on Learning (Boyd et al, 1997)
- Competency-based Approach to Comprehensive Pregnancy (Johnson et al, 2000)
- Solution Focused Approach (De Jong and Berg, 1994)
- Community as Partner Model (Anderson & McFarlane, 1996)
- Home Visitor
- “Invest in Kids” model with components from  “Wisconsin” and “Within our Reach” models

**Notes:**
Nurse Intervention
The Nurse intervention was based on a holistic and universal approach which acknowledged physical, emotional and spiritual elements of pregnancy. The intervention was primarily office based with off site visits when preferred.  Women typically met with the Nurse prior to, or on the day of, their first scheduled office visit. The initial intake visit took approximately 60 minutes.  During this initial visit, a 24 hour food recall was conducted and a range of topics were explored to identify the goals and needs of the mother. Topics included nutrition, social and practical support, lifestyle, resources and educational videos, food security, psychosocial health and abuse, identification of potential medical complications, and exercise. Because the program was designed to be client specific, the client and the Nurse together determined the frequency and the duration of the visits based on pregnancy-related goals. The Nurses saw women up to the time of delivery. A courtesy post partum telephone call or visit was made, and the Nurse gave women a card congratulating them on the birth of their baby. The Nurse provided both emotional and nursing support during the intervention.

The Home Visitors worked with the Nurses in an effort to reduce duplication of services and to best address priority goal areas for each woman.  The Home Visitors focused on social support, practical assistance, supporting optimal prenatal health and connecting the client/family with community resources.  The home visiting program was also client specific, so the client and the Home Visitor together determined the frequency and duration of the visits based on the pregnancy related goals. One courtesy post partum telephone call or home visit was also offered to participants. The Home Visitors provided non-medical, peer-like practical support during the intervention.

## Results

**Study Group**
**•**** ****Control**
**•**** ****Nurse**
**•**** ****Nurse + Home Visitor**

- CPC Women
- Average 29 yrs
- 54% no previous children
- 98% had a partner
- 75% Caucasian
- 75% earned 40K+/yr
- 73% post-secondary education
- CPC Babies
- Average 3,400 grams
- 7.1% pre-term
- 4.8% low birth weight

**Notes:**
Demographics did not differ by study group

## Intervention Intensity

- 49% of women with Nurse support had 4 or more visits
- Range 0 – 11 visits
- Duration approximately 60 minutes on 1st visit
- 54% of women with Home Visitor support had 2 or more visits
- Range 0 – 14 visits
- Duration approximately 75 minutes
- There was increased resource uptake with increased use of support

**Notes:**
60% of women would see Nurse again in future pregnancy

30% of women would see Home Visitor again in future pregnancy

## What Happened

**Notes:**
Early bird: 23, 32, 27
parenting classes DURING 11.4,18.9,15.7  
parenting classes AFTER8.7, 11.8,11.2 (not significant)
Overall rates of using  dietician= 12
Overall rates of using ‘FH thru Mat = 87.9
Overall rates of post partum BF =32.5 (range 28.8-37.9)

Significantly more women in intervention groups had more information on numerous pregnancy and parenting topics.

## Interesting Findings

-  Some resources included:

| Written material
Early start help line
Prenatal classes
Breastfeeding	
Resource libraries
Parenting classes | 89%
52%
49%
48% 
24%
22% |
| --- | --- |

-  Over 50% of women used 3 or more resources

**Notes:**
Early bird: 16.9, 28.4,23.1
parenting classes DURING 11.4,18.9,15.7  
parenting classes AFTER8.7, 11.8,11.2 (not significant)

Overall rates of using  dietician= 11.5
Overall rates of using ‘FH thru Mat = 87.9
Overall rates of BF support during OR after pregnancy = 48%
Overall rates of post partum BF =32.5 (range 28.8-37.9)

COMMENT ON LOW UPTAKE OF PARENTING AND RESOURCE LIBRARIES – OPPORTUNITY FOR INCREASED USE

## What Didn’t Happen? 

- Although women received more information on the following, there were **no OVERALL differences** in:
- Abuse and neglect
- Use of food bank, housing supports
- Smoking rates and alcohol consumption
- Post natal depression
- Partner support post delivery
- Satisfaction with services

## Subtle Findings

- Need and Benefit:
- 81% of women reported benefit from the Nurse and 43% indicated need of this service
- 43% of women benefited from the Home Visitor and 22% indicated need of this service

- Characteristics of women more likely to report need of additional support:
- first birth
- young maternal age
- low income
- non-Caucasian ethnicity

- abuse
- negative network orientation
- low-self esteem

## Who Needs the Extra Help?

- Aged 18-24
- Born outside Canada
- Lived in Canada <2 years
- Annual income < 40K year
- No previous children
- Under-employed
- History of sexual abuse, neglect or alcohol problems

- Never taken prenatal or parenting classes
- Lower self esteem
- Lower social support
- Women waiting longer for specialized care provider

- Women attending the prenatal clinic situated in a multi-cultural, low income quadrant of the city had more of these characteristics.

## Associated Costs

- Standard care
- $1,487 / mother
- Mean cost of additional Nursing care
- $90.90 / mother
- Mean cost of additional Nurse + Home Visitor
- $170.90 / mother

## Conclusions 

- Support increased information received and utilization for some resources
- A key opportunity exists to identify and support those who would most need additional support
- Those with risk characteristics reported greatest benefit
- Economic analysis suggests acceptable cost burden, particularly if allocated to high-risk women
- Normalization of help seeking behavior through improved visibility and universal screening

## Public Health Implications 

- Current efforts in the Calgary Health Region underway to re-design service delivery to better meet the needs of our community

## Who We Worked With 

- Calgary Children’s
- Initiative
- Calgary Immigrant Women’s Association
- University of Calgary
- Pediatrics
- Community Health Sciences
- Centre for Health and Policy Studies

- 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

## The CPC Study Team